JRS TEF

This video demonstrates a thoracoscopic repair of a type 3 TF in a 2.6 kg full-term infant using the JRS 3 millimeter sealer. The room set up is as shown. The patient is placed in a modified lateral decubitus position with the right side elevated only about 30 degrees. The surgeon and the assistant stand at the patient's front, and the monitor is at the patient's back. Here you see the positioning with the patient tilted forward approximately 30 degrees. The trochar placement is as follows. The scope port is placed first and is placed behind the tip of the scapula in approximately the 4th intercostal space. The right and left hand operating ports are placed in the axilla and directly below the scope port to allow for a 90 degree confluence at the site of where the anastomosis will be sutured. Upon entering the chest, the azyous vein is identified and dissected out using the 3 millimeter sealer. Here the azyous vein is approximately 4 millimeters in diameter. It is sealed proximately and distally with the sealer. And then divided sharply. The sealer provides excellent hemostasis, with little risk of bleeding or other issues. Some people choose to leave the agus vein intact during this portion of the dissection. However, concerned for disrupting it or causing bleeding. Can be a factor in further. Dissection during the operation. The initial Steps are to dissect out the lower esophageal segment. Here you can see the lower esophagus and see it inflating with each breath. The patient has just a tracheal intubation. No attempt is made to perform a main stem intubation. Lung collapse is achieved by insufflating CO2 at a pressure of 4 at a flow of approximately 1 L per minute. As we just further dissect out the lower esophageal fistula, it becomes apparent that the fistula is entering the carina right at the bifurcation. This is Described as a trifurcation fistula. This means the gap is much larger than was initially thought because of the low entrance of the fistula at the bifurcation. The lower fistula is dissected out using the 3 millimeter sealer, and the section is carried all the way up into the crotch of the bifurcation of the right and left main stem bronchus. Test clamping is performed to ensure that. This section is carried as proximately as possible. Once this is done. The fistula can either be suture ligated, or in this case, we choose to use a 5 millimeter endoscopic clip. The right hand axillary port. Is changed from a 3 to a 5 to allow for. Placement of the endoscopic clip. This provides a very atraumatic and quick way to secure the fistula. And we prefer this to suture ligation. Now the upper pouch is dissected out. The anesthesiologist applies some downward pressure on the nasogastric tube and helps identify the upper pouch. Section around the pouch is then performed circumferentially using the. Sealer As a dissector, as well as a tissue sewer. Small connective tissue strands or grafts adjacent to the pouch and then. Upward traction is used to gently distract them away from the pouch. The muscular wall of the pouch becomes more and more evident as the dissection continues. Because of the The low nature of the lower pouch and a rather extensive dissection of the upper pouch will be performed in order to overcome the gap which appears to be approximately 4 vertebral bodies. By dissecting up into the thoracic inlet. Adequate length of the upper pouch can be obtained. Here you can see the sealer being used to dissect between the membranous wall of the trachea and the pouch. Often there is dense connective tissue in this area, and this portion of the dissection can be quite difficult. By grasping small amounts of tissue in the apparent plane, sealing, and then gently distracting the tissue away from the upper pouch down towards the trachea, the oesophageal pouch can safely be dissected off of the membranous trachea. It is often helpful to circumferentially dissect around the upper pouch uh in order to help better identify the most difficult plane which lies between the esophageal pouch and the membranous trachea. Here you can see some very dense attachments at the lower end of the pouch. Initially, there was some question of a possible upper pouch fistula, but as the dissection continued, uh, it became apparent that there was not one present. However, to better investigate this portion of the. Uh, this section was performed sharply to make sure that a small upper pouch fistula was not missed. Once this last fibrous connection is divided, the upper pouch becomes much more mobile. Again, the sealer is used to take down the final fibrous attachments between the membranous trachea and the pouch. This is an extremely safe way to do this portion of the mobilization, minimizing the risk of injury to the upper oesophageal pouch or the membranous wall of the trachea. This portion of the dissection is much safer with the sealer than with a hook cautery, um, as we have previously used. You can see how the, the sector allows you to dissect well up into the thoracic inlet. And at this point, the dissection is well up into the neck. Gaining a great deal of length in the upper pouch. At this point, the upper pouch can almost be pulled all the way down to the bottom of the crina of the. Right and left main stem bronchus. There's some final dense adhesions between the upper pouch and the membranous trachea, and again, these are taken down by gently grasping the tissue, sealing it, and then Detracting it down towards the membranous trachea. As you can see, there is no heat spread damage to any of the surrounding structures allowing us to dissect in this fine small plane. We now return to the lower pouch uh fistula. This was not divided initially as the lower pouch tends to retract once this division. I performed and making it more difficult to find. We therefore wait till we're ready to perform the anastomosis prior to cutting it. Also because of the uh rather large gap because of the low nature of the lower. Uh, pouch fistula. Some mobilization of the lower esophageal segment is performed using the sealer. The anterior and posterior vagus nerves are easily visualized, and these are carefully dissected off. The esophagus. In order to prevent injury to these structures. Again, grasping small amounts of tissue, sealing them, and then distracting them down allows us to safely dissect it. The lower pouch os is also dilated with the sealer, as was seen. Now the two pouches are brought together to show that there is adequate mobilization to allow for the anastomosis. There is some tension on this because of the Longer gap than is routine for a type 3 fistula, so a bit more mobilization of the lower pouch is performed. And see how the vagal nerves are preserved. During this portion of the dissection. The tip of the upper pouch is then uh. Amputated Uh, usually one gets through the muscular layer and then has to reach in and grab. The submucosa in order to uh complete the enterotomy through the mucosa. Generally, we completely amputate the tip to ensure that there is a good oss for the anastomosis. Here you can see the mucosa being pulled down and. In size Now the mucosa of the upper pouch esophagus is readily apparent. In this case, we're not completely amputating the tip as we will use this. Piece of tissue to act as a handle to help manipulate the upper pouch. While retracting down on this, a stitch is placed in the middle of the back wall, making sure it is full thickness. And an adequate bite of tissue. Again, this gap appears to be about 4 vertebral bodies. Prior to the complete mobilization. The stitch goes from inside out on the upper pouch to outside in on the lower pouch. And then in this case, we will use a knot pusher to place the initial stitch because of the significant tension on the two ends. You can see that the upper and lower pouch come together nicely. And the knot pusher is used to uh complete knotting the stitch. With the two ends now approximated, a number of. 50 PDS sutures will be placed. The back row is placed, uh, going from inside out on the upper pouch to outside in on the lower pouch. Care should be taken with each bite to make sure all of the bites are full thickness, including an adequate bite of the muscular wall and then mucosa. The rest of the sutures are tied intracorporeal. To minimize any pulling or stress uh on the. The soft sel walls. Usually there are. 4 to 5 stitches in the back row. And then an additional 4 to 5 stitches in the front row. General 4 to 5. Throws replaced to secure an adequate knock. Care should be taken not to put. Significant tension. On the suture. Or on the. esophageal segments as the knots are being tied. The 3rd stitch is now placed approximating the more posterior portion of the back wall. Often these can be done in one bite uh by laying the lower esophageal segment over the tip of the needle. In the desired location. The true key to this operation is definitely mobilization of the upper pouch. And again, the use of the sealer allows very safe dissection well up into the neck. We easily doubled the length of the upper pouch which was available. To pull down into the chest by doing an extensive dissection up into the neck in this particular case. The visualization of that portion of the operation thoracoscopically, uh, it's much greater than when trying to perform this portion of the operation through an open thoracotomy. The back corner stitch is now being placed. And therefore, we're transitioning from having to stitch the knots being intraluminal to extraluminal. Uh, usually, this can be achieved by gently rolling the esophagus medially exposing the back wall. And again, 4 to 5 throws are placed uh with each. For each knot to Ensure that it is secure and will not slip. With the back corner intact, we'll now place the front corner stitch. And you can see that it's full of thickness, incorporating a good bite of mucosa. Going from the outside in and then on the lower segment. Inside Out. Care should be taken with all of the back row of stitches and corner stitches, not to grab the anterior wall, which could um close off the lumen. Even though the ends are on the somewhat significant tension. Uh, the sutures lie down nicely without tearing. And we're getting a very nice secure anastomosis. One tail is left a bit longer and this allows us to roll the esophagus to help with placement of later sutures. The back corner is now placed in a similar fashion again, the suture going from outside in to inside out. And the two ends are gently brought together by placing slow traction on the suture. One can see that there are no significant gaps between the individual sutures. With the back wall and corners now done. The nasal or oral gastric tube is then advanced by the anesthesiologist down through the anastomosis into, into the lower esophageal segment and all the way down to the, into the stomach as you see here. We leave this tube for 5 days, 4 to 5 days, uh. And remove it. Usually on the 4th postoperative day when we obtain a contrast study to ensure there is no leak. With the tube in place, the anterior wall sutures can now be placed. These can usually be placed in a single bite, but again, care must be taken to obtain good bites and include mucosa in all bites. In this particular case, 3 anterior wall sutures will be all that's necessary to complete the anastomosis. This procedure took 75 minutes, and the child tolerated the surgery extremely well. This particular child had no other congenital anomalies. A contrast study was obtained on the 4th postoperative day which showed no evidence of leak. And feeds were started. The child was on full feeds. By the 8th postoperative day. The Child maintained saturations in the mid-90s throughout the procedure with entitled CO2s around 40. Again, the child did not have single lung ventilation, but had a tracheal intubation. Which, uh, he tolerated quite well. We collapse the lung using a constant flow of 1 L per minute of CO2 at a pressure of 4. And had no problems with overventilation or visualization during the procedure. It's extremely important to work closely with the anesthetist to achieve uh. This degree of visualization. Throughout the procedure. With the last stitch placed, uh, the lower trochar is removed and an 8 French chest tube is placed next to the anastomosis. Here you see the completed Maskimos.