Thoracoscopic H-Type Fistula Repair in a 10-Year-Old Child: Technical Points and Challenges

Introduction:

H-type fistula accounts for 5% of congenital tracheoesophageal anomalies. About 30% of these are located below the 2nd thoracic vertebra and are better repaired by a thoracic approach. ^1,2 We present the technique and challenges of thoracoscopic repair of a H-type tracheoesophageal (TE) fistula in a 10-year-old girl. The video run time of this video is 5 minutes 37 seconds.

Materials and Methods:

This 10-year-old girl presented with cough during feeding and recurrent respiratory infections from birth. A HRCT thorax revealed a H-type TE fistula below the level of the 2nd thoracic vertebra.

Operative Technique:

The child was anesthetized with laryngeal mask and a 14F nasogastric tube was inserted A flexible bronchoscopy confirmed the position of the fistula to be well below the suprasternal notch (by transillumination). The fistula was canulated with a flexible guidewire and the airway secured with a cuffed endotracheal tube alongside the guidewire. The child was strapped in a near left lateral position at around 70°. Pneumothorax was established by the open technique using a 5 mm port in the right 5th intercostals space along the anterior axillary line using CO₂ at 4 mm of water. Other ports were placed shown in the video. The superior mediastinum was visualized and the lung apex was retracted to display the azygous vein entering into the superior vena cava. The mediastinal pleura above the azygous arch was raised as a superiorly based flap and paratracheal lymph nodes were excised to expose the TE groove. The esophagus was encircled with an umbilical tape. The TE fistula was isolated by blunt dissection. This step was challenging due to the working angles and was made possible by pushing a piece of umbilical tape deep into the fistula and retrieving it from above. The fistula was then transfixed with a 3-0 Vicryl suture. The umbilical tape was again used to guide the suture (by taking a bite through the tape) behind and around the fistula to encircle it for ligation. The fistula was ligated after retrieving the guidewire from the child's mouth. A clip was not considered for this short and wide fistula. The esophageal end of the fistula was divided and the opening in the esophagus was closed with a continuous 3-0 Vicryl suture. The pleural flap created initially was now interposed between the closure lines in the trachea and esophagus. An additional pleural flap based just lateral to the upper fourth part of the thoracic esophagus was harvested (diagram included in the video) and inserted into the lower part of the groove. A 20F chest tube was placed. The wounds were closed with 4-0 Vicryl and bioadhesive glue(Amcrylate). Total blood loss was about 30 mL. The child made a quick recovery. A postoperative barium swallow on day 10 revealed no leak. She was then started orally. She has remained well at follow-up of 8 months.

Conclusions:

The low variety of H-type TE fistula can be safely repaired thoracoscopically.

No competing financial interests exist.

Runtime of video: 5 mins 37 secs