Thoracoscopic Repair of Proximal H-Type Tracheoesophageal Fistula

Abstract

Introduction:

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (TEF) is an accepted technique with equivalent outcomes to open repair. ¹ In contrast, TEF without esophageal atresia (H-type) is predominantly repaired open via a transcervical approach with a reported recurrent laryngeal nerve injury rate of 50%. ² Thoracoscopic repair of H-type fistulae may theoretically result in lower complication rates because of the magnified and improved optics obtained with advanced cameras; however, it is contraindicated by current literature to repair H-type fistulae located above the second thoracic (T2) vertebral level thoracoscopically. ^{3 –6} This video shows thoracoscopic repair of an H-type TEF located at the fifth–sixth cervical (C5–C6) vertebral level.

Materials and Methods:

A 16-month-old girl with a history of chronic cough and feeding difficulty was referred to the pediatric surgery clinic with a diagnosis of TEF. An extensive work-up, including combined esophagoscopy and bronchoscopy, identified an H-type TEF located at the C5–C6 vertebral level. The patient was taken to the operating room for thoracoscopic TEF repair. Repeat bronchoscopy was performed immediately preoperatively to confirm the location of the fistula. With a combination of bronchoscopic and esophagoscopic guidance, a ureteral catheter was looped through the fistula to aid in intraoperative identification. The patient was then placed in a modified left lateral decubitus position turned 45° prone. A 5-mm camera port was inserted just posterior and inferior to the tip of the right scapula, and three additional 3 mm working incisions were made; one in the fourth intercostal space at the anterior axillary line, a second in the sixth intercostal space at the mid axillary line, and a third in the eighth intercostal space posterior to the camera port to assist with retraction. On initial visual assessment the azygos vein, vagus nerve, and phrenic nerve were all easily identified near the apex of the pleural cavity and were preserved throughout the case. The parietal pleura was incised over the trachea, and the TEF was identified using blunt dissection and the aid of the previously placed ureteral catheter. The fistula was located high in the thoracic cavity above the level of the subclavian artery and vein. Once the fistula was circumferentially dissected free of surrounding connective tissue it was isolated with a vessel loop. The ureteral catheter was removed from the airway and a single fire of the 5 mm endoscopic stapler was used to ligate and divide the fistula. There were no operative complications. Intraoperative laryngoscopy confirmed normally functioning vocal cords at the conclusion of the case.

Results and Conclusions:

The patient had an uneventful recovery and was discharged home on postoperative day two. One-month follow-up confirmed resolution of preoperative symptoms. This case demonstrates that a thoracoscopic approach is both feasible and effective in repairing H-type TEF above the T2 vertebral level. Thoracoscopic TEF repair is not only less invasive than transcervical repair, but may also confer a lower risk of injury to the recurrent laryngeal nerve as it allows for good observation of all thoracic inlet structures.

No competing financial interests exist.

Runtime of video: 4 mins 54 secs