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Thoracoscopic Repair of Esophageal Atresia with Distal Tracheo-esophageal...
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Esophageal Atresia 55 items
Chapter 1 of 3 · Surgical Management
Azygous division
Patient positioning and azygous vein division
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The patient is a term male newborn with esophageal atresia and distal tracheoesophageal fistula.
The patient is placed in the left lateral decubitus position with the arm extended and restrained, with a roll under the left axilla.
Division of the azygous vein typically leads the surgeon to the fistula site.
The azygous vein is dissected by opening pleural windows with blunt dissection and cautery above and below its transverse segment, a good distance away from its last tributary.
The azygous vein can be divided with an energy device, or it can be simply coagulated, or double clipped and divided.
The magnification (of thoracoscopy) allows for excellent delineation of the trachea and esophagus.
Once the fistula is well dissected, it is ligated with a suture ligature flush with the trachea, but not divided, to prevent the distal esophagus from retracting.
Asking the anesthesiologist to push on the nasoesophageal tube aids in the dissection of the proximal esophageal stump.
The proximal esophageal dissection should be performed with great care, as the esophagus is often quite adherent to the trachea and may even share a common wall.
A combination of sharp and blunt dissection is used for mobilizing the proximal esophagus.
The dissection of the proximal esophagus can be continued to the thoracic inlet, resulting in excellent mobilization.
The fistula is divided a few millimeters distal to the ligature to liberate the distal esophagus.
Following division of the fistula, the fistula ligature should be tested with 25 to 30 centimeters water positive pressure ventilation.
The blind end of the proximal esophagus is divided to visualize the lumen before anastomosis.
The back wall (posterior wall) anastomosis is completed first, using interrupted 4-0 or 5-0 absorbable sutures.
In this case, extracorporeal knot tying was used, as the two ends came together nicely with minimal tension.
Sutures are placed 2 to 3 millimeters apart for the posterior wall anastomosis.
Five to six sutures usually suffice to complete the posterior wall anastomosis.
The nasoesophageal tube is advanced to protect the posterior wall prior to starting the anterior wall anastomosis.
It is important to take full thickness bites of healthy esophageal wall and mucosa with each suture.
Fewer sutures are usually required for the anterior wall anastomosis than for the posterior wall.
The nasoesophageal tube is removed following completion of the anastomosis.
In this case, a chest tube was placed; however, chest tube placement is no longer routinely used.