Right Thoracoscopic Repair of an H-Type Tracheoesophageal Fistula

Introduction: Although H-type tracheoesophageal fistulas (TEFs) are routinely repaired using a neck incision, thoracoscopic repair is a feasible, and potentially advantageous, alternative to the management of this anomaly.1 This video demonstrates effective treatment of an H-type TEF using a right thoracoscopic approach. Methods: Our patient is a 3-month-old female with severe combined immunodeficiency and suspected CHARGE syndrome, who presented with difficulty swallowing and likely aspiration. She underwent a swallow study that was positive for aspiration as well as reflux. A bronchoscopy was then performed that showed an H-type TEF in the lower neck. She was taken to the operating room for a right thoracoscopic repair of her H-type TEF. The patient was placed in the left lateral decubitus position and the procedure was performed using three ports: a camera port behind the tip of the scapula at approximately the fourth intercostal space, a working port directly below the camera port, and a working port anterior to the camera port at the midaxillary line. Upon entering the chest, we first identified the trachea and then dissected in the tracheoesophageal groove using a combination of blunt dissection and a bipolar energy device. After careful dissection, the TEF was identified, and it was then dissected out circumferentially using blunt dissection. The fistula was then divided using two 5-mm staplers. After complete transection was achieved, a pleural flap was placed between the staple lines of the trachea and esophagus to help prevent a recurrent fistula. The parietal pleura was then closed over the trachea and esophagus. Results: The patient tolerated the procedure well. She underwent a swallow study on postoperative day 2, which was negative for a leak and she was started on feeds. Conclusions: Thoracoscopy is an effective alternative approach to repairing an H-type TEF. Advantages are that it allows for direct and magnified observation between the esophagus and the trachea, it also allows to see the vagus nerve clearly and avoid injury to the recurrent laryngeal nerve, and it avoids a neck incision. SR: Ownership in JustRight Surgical; SA: no competing financial interests exist. Runtime of video: 3 mins 48 secs Presented at IPEG, April 13, 2018, in Seattle, Washington.