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Original Article

Thoracoscopic repair of esophageal atresia with

tracheoesophageal fistula: Basics of technique and its nuances
Ravi Prakash Kanojia, Neerja Bhardwaj1, Deepak Dwivedi1, Raj Kumar, Saajan Joshi1,
Ram Samujh, K. L. N. Rao
Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, 1Department of
Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Address for correspondence: Dr. Ravi Prakash Kanojia, Block 3A, Advanced Pediatric Center, Postgraduate Institute of Medical
Education and Research, Sector 12, Chandigarh ‑ 160 012, India. E‑mail: drravikanojia@yahoo.com

ABSTRACT Access this article online

Website: www.jiaps.com
Aim: To review the technique of thoracoscopic repair of esophageal atresia with DOI: 10.4103/0971-9261.182585
tracheoesophageal fistula (TREAT) and results reported in literature and with authors’ Quick Response Code:

experience. Patients and Methods: The technique of TREAT was reviewed in detail
with evaluation in patients treated at authors’ institution. The patients were selected
based on selection criteria and were followed postoperatively. The results available in
literature were also reviewed. Results: A total of 29 patients (8 females) were operated
by TREAT. Mean age was 2.8 days (range 2–6 days). Mean weight was 2.6 kg (range
1.8–3.2 kg). There was a leak in four patients, and two patients had to be diverted.
They are now awaiting definitive repair. Twenty‑one patients have completed a mean
follow‑up of 1.5 years and are doing well except for two patients who had a stricture
and underwent serial esophageal dilatations. The results from current literature
are provided in tabulated form. Conclusions: TREAT is now a well‑established
procedure and currently is the preferred approach wherever feasible. The avoidance
of thoracotomy is a major advantage to the newborn and is proven to benefit the
recovery in the postoperative patient. The technique demonstrated, and the tweaks
reported make the procedure easy and is helpful to beginners. The outcome is very
much comparable to the open repair as proven by various series. Various parameters
like leak rate, anastomotic stricture are the same. The outcome is comparable if you
TREAT these babies well.

KEY WORDS: Esophageal atresia, neonatal laparoscopy, thoracoscopy, tracheoesophageal

fistula

INTRODUCTION
Repair of esophageal atresia with tracheoesophageal
fistula (EA‑TEF) is the epitome of neonatal surgery.
We have read this statement in almost every textbook
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of pediatric surgery and stand true in its meaning.
The open EA‑TEF repair is a test of surgical skills of a
pediatric surgeon. The postoperative management is
also considered a test of standards of neonatal care. In
the current era of laparoscopic surgery with the advent
For reprints contact: reprints@medknow.com
Cite this article as: Kanojia RP, Bhardwaj N, Dwivedi D, Kumar R,
Joshi S, Samujh R, et al. Thoracoscopic repair of esophageal atresia with
tracheoesophageal fistula: Basics of technique and its nuances. J Indian
Assoc Pediatr Surg 2016;21:120-4.

120 © 2016 Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow
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Kanojia, et al.: TREAT for EA-TEF

of smaller size instruments, the repair of this complex laparoscopically, and we have avoided such scenarios
anomaly is now practiced by minimal access surgery in the early part of our experience. A known cardiac
and is the current state of the art.[1] The thoracoscopic abnormality is another relative contraindication to
repair of esophageal atresia with tracheoesophageal this procedure as it is with any other laparoscopic
fistula (TREAT) is now being practiced at various procedure due to issues related to oxygenation during
centers across the world and India is not far behind. anesthesia. Right aortic arch is one such anomaly
The series reported so far [Table 1] have shown the where the anatomy is distorted, and it is difficult to
feasibility and comparable (even better) results with manoeuvre around in small space and is difficult to
the open technique. The present discussion will try accomplish thoracoscopically.
to outline the basics of the technique and some of the
practical details which can help a pediatric minimal Positioning and anesthetic and ventilation strategy
access surgeon to adopt the technique. The paper also The patient is positioned in similar manner as in
reviews the results available in literature including open surgery. There is minimal rolling of the table to
authors’ experience. make the patient somewhat semi‑prone and closer to
surgeon and on left edge of table [Figure 1]. There will
THE TECHNIQUE be a preplaced upper pouch identification tube before
draping. The intubation is done in a way that the ET
Timing, patient selection, and preparation tube bevel is away from the fistula. We have used the
If the condition is detected at birth within the first technique of lung isolation using the Fogarty balloon
few hours, the initial management is same as one occlusion. It works well and acts as an on‑off switch
would prepare for open repair. Similarly, the patients for the right lung. The Fogarty placement is done by
presenting late will need preoperative stabilization and bronchoscopy and the occluding balloon is placed
some basic investigations. This will include routine under vision [Figure 2]. The preoperative bronchoscopy
hematological investigations and imaging. The imaging although adds time to the entire procedure also
will be chest and abdomen X‑ray to see the level of gives added information on the level of fistula. Some
upper pouch. The patient selection largely depends surgeons prefer to place a guide wire to be sure of fistula
on three factors weight, overall general condition and identification during thoracoscopy, though this is not
the level of upper pouch. In general, low birth weight, our practice.
septic babies tend to tolerate hypercarbia, and hypoxia
very poorly and do not sustain the longer duration of Ports and instrumentation
the procedure hence are less suitable. Similarly, the The ports used are 5 + 3 + 3. The first optical port is
long gap atresias with  gap more than vertebral length planned as per the surface anatomy after positioning
are difficult to handle at the time of anastomosis the patient [Figure 1]. The surgeon has to see the
triangulation is perfect because in an infant every
Table 1: Summation of major series reported in literature millimeter of space will make a large difference. The
for thoracoscopic repair of esophageal atresia with port positions are shown in Figure 1. The 5 mm port is
tracheoesophageal fistula placed by open method somewhere near the anterior
Publication year Author Number of patients axillary line close to the lower chest so that there is
2015 Rothenberg and Flake[2] 14 long gap pure leverage to move in and out. The target is to align the
esophageal atresia scope with the transverse fissure to avoid lung lobes
treated by treat
occluding the view. The subsequent two ports are then
2015 Nachulewicz et al.[3] 10
placed by seeing the anatomy from inside trying to space
2015 Robie[4] 8
out and triangulate. The right‑hand port usually lands
2014 (Spanish) García et al.[5] 20
below and medial to the tip of the angle of scapula. The
2015 Okuyama et al.[6] 58 (multi‑institution)
3 mm instruments used are the hook, Maryland, bowel
2014 Koga et al.[7] 25 compared with 40
open repair patients grasper, and fine scissors.
2014 Yamoto et al.[8] 11 compared with 15
open repair patients STEPS
2013 Rothenberg[9] 51
2012 Huang et al.[10] 33 (from 2 centers) Identification of regional anatomy
2013 Dingemann et al.[11] 22 Once inside the lung is made to collapse with gentle
2009 Patkowsk et al.[12] 23 pressure by instruments by pressing them and by
2008 AL Tokhias et al.[13] 23 4–6 mm of intrathoracic pressure. The major landmarks
2014 Lee et al.[14] 23 identified are the azygos vein, vagus nerve [Figure 3].
2005 Holcomb et al.[15] 104 (6 institutions) The subclavian at the apical area. If not known before

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Kanojia, et al.: TREAT for EA-TEF
Figure 1: Patient position on the left edge of table with surface markings
and port sites
Figure 2: Fogarty balloon placed bronchoscopically occluding the
right bronchus
Figure 3: Regional anatomy at initial entry
the surgeon will be able to see the right aortic arch if
present at this time. The anesthetist then pushes the
122 Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2016 / Vol 21 / Issue 3
upper pouch with the preplaced feeding tube helping
to identify the position and distance; this then decides
the pace of the procedure because now you know the
exact gap distance.
CONTROL OF FISTULA – THE ESOPHAGEAL HITCH
The endothoracic fascia is incised to identify the
medially curving lower pouch with the vagus nerve
overlying it. This is precisely found below the azygos
and easily identified with the expansile impulse
synchronized with ventilation. The lower pouch fistula
is then gently grasped with the nontraumatic bowel
grasper and dissected preserving the vagus nerve. We
prefer to gently hitch the fistula with a 4/0 prolene to
the chest wall. This serves two purposes. It keeps the
left hand free for aiding in dissection and also prevents
air going down to the stomach through the fistula. The
fistula once hitched shows the T‑junction with the
trachea precisely, and this can now be transfixed just
the way it is done in open surgery. Once the fistula is
transfixed we do not divide it at the same time as it
will retract and fall away towards diaphragm, rather
the hitch stitch is now relaxed, and the surgeon now
concentrates on the upper pouch.
DIS SECTING THE UPPER POUCH AND ITS
MOBILISATION
While an anesthetist is probing the oro‑pouch tube
from above, the upper pouch is identified, and the
fascia above it is incised with hook. The upper pouch
is now gently grabbed in the nontraumatic bowel
grasper and lifted up. The crucial part of dissection
lies in the medial aspect where the upper pouch is to
be separated from the trachea. This dissection is sharp,
and a good scissor is a great asset for this step. The
upper pouch is mobilized all around to gain length
and at the same time, a rare upper pouch fistula is
ruled out. Once mobilized the pouch is opened with
an oblique cut and the two ends are now prepared
for anastomosis. It is at this point, the hitch looping
he lower pouch fistula is now lifted again, and the
fistula is divided.
ANASTOMOSIS‑THE FIRST STITCH
The first stitch is the difficult stitch because the two
ends tend to fall apart, and one may have to take a longer
length suture (12 cm) for this step. Although the position
of knot does not matter the knot lying outside makes the
anastomosis look neat. Once the first knot is in placed
the posterior row sutures are done one on either side of
the midline making sure mucosa is included following
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Kanojia, et al.: TREAT for EA-TEF
which size 6 nasogastric tube is passed through the
anastomosis. The anastomosis is then completed and
at the most 5–6 knots are required for completion. The
anastomosis is more about laparoscopic suturing skills
in small space.
Concluding the operation
After the anastomosis is done, the area is then washed
with warm saline and the operation concludes with
the placement of a 14 Fr chest drain exiting through
the 5 mm port placed under vision. The 3 mm ports do
not require any closure except for the skin. The local
incision sites are infiltrated with local anesthesia,
and the patient is handed over to the anesthesia team
with the caution to secure the nasogastric and prevent
pulling out during turning and shifting the patient.
The chest drain is checked for water level and any
air leaks.
Postoperative management: The postoperative
management is no different from the conventional
repair except for the fact that in the absence of a
thoracotomy the ventilator requirements are far less
and so are the pain medications.
Role in long gap atresia and other conditions
With growing experience the surgeon can attempt the
longer gap TEF, which pose greater difficulty at the time
of anastomoses. Rothenberg and Flake have reported
14 such patients.[2] For patients with poor general
condition simply clipping the fistula and then later
going in for anastomosis is an attractive option and
gives the advantage to the child as the sans thoracotomy
procedure is easily tolerated by the infant even if the
condition is poor.
Postoperative and follow‑up management
Once stabilized the infant undergoes an esophagogram
if there is no evidence of a leak in the chest drain and
the orals feeds are supplements with the ongoing tube
feeds. The chest drain is removed following 1st day of
feeds and decision to discharge is then taken by the
Intensive Care Unit team based on the well‑being of
the child.
Review of literature and its results with our experience
The first case of thoracoscopic repair was reported by
Lobe et al.[16] in 1999 which was reported as surgical
first. This was followed by Rothenberg reporting
again in the year 2000 in a newborn infant.[17] Since
then there are several series coming from various
centers across the world reporting TREAT. Table 1
gives a short summary of major series reported so far
(series with 10+ patients). The outcome reported in
these series have uniformly been demonstrated to be
Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2016 / Vol 21 / Issue 3
good with conversion rate of <10%. There are several
series which have compared open versus TREAT. Koga
et al.[7] compared 45 patients of open repair versus 25
of TREAT and concluded it to be better on various
parameters such as lung function and postoperative
recovery. A larger data set comparison was done in
a multi‑institutional analysis of TREAT with that of
large open series of open repair reported in literature
by Holcomb et al.[15] they aggregated 104 patients of
TREAT from 6 centers across the world and concluded
that musculoskeletal sequele is much less. The need
for esophageal dilatation and fundoplication later
are no different from the open repair and ultimately
concluded that TREAT is safe and efficacious. A
similar multi‑institutional analysis was done by
Okuyama et al.[6] They aggregated 58 patients from 7
institutes. They also reported comparable results with
open repair.
The author’s experience
Our current experience is quite limited in number.
Still we have been able to make refinements in the
steps of the complex operative procedure to make it
easy for surgeons wanting to adopt this procedure.
The author advocate the use of a Fogarty balloon
occlusion to control the ventilation of right lung this
will, in turn, obviate the need of 4th port which have
been used by many surgeons for retraction of the
lung. It is really difficult to maintain the ergonomics
in a small chest area of a newborn with 4 ports. The
Fogarty balloon acts as an on‑off switch for the lung
and avoids use of higher pneumothorax pressures
during the procedure. The other tweak is the use of
the lower pouch esophageal hitch which helps in
accurate dissection and control of fistula. We have
shown that it is possible to spare the azygos vein
during TREAT and anastomosis is possible above
and medial to azygos. This has benefit in avoiding
edema in the lower pouch and decreasing the leak
rate. This fact needs further verification and evidence
through trials.
Since 2012, a total of 29 patients (8 females) were
operated by TREAT. Mean age was 2.8 days (range 2–6
days). Mean weight was 2.6 kg (range1.8–3.2 kg). Four
were converted into open due to difficulties as poor
anesthetic stability and long gap (2 out of the 4). The
long gap patients when converted were difficult to
anastomose. The mortality in this series was 6 and is
attributed to sepsis. These patients were the one who
had initially come in poor condition. There was leak
in four patients, and two patients had to be diverted.
They are now awaiting definitive repair. Twenty‑one
patients have completed a mean follow‑up of 1.5 years
and are doing well [Figure 4] except for two patients
123
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Kanojia, et al.: TREAT for EA-TEF
Figure 4: Follow-up esophagograms done at 3 months of follow-up
who had stricture and underwent serial esophageal
dilatations. We have currently undertaken a study to see
the anastomotic caliber in these patients in follow‑up
and comparing it with open repair to see if there is any
difference.
CONCLUSIONS
TREAT is now a well‑established procedure and
currently the preferred approach wherever feasible.
The feasibility depends on surgeons experience the
equipment available and the anesthetic expertise.
The avoidance of thoracotomy is a major advantage
to the newborn and is proven to benefit the recovery
in postoperative patient. The technique demonstrated
and the tweaks reported for the control of lung
ventilation with Fogarty catheter and lower pouch
hitch makes the procedure easy and is helpful to
beginners. The outcome is very much comparable to
the open repair as proven by various series. Various
parameters like leak rate, anastomotic stricture are the
same. The pediatric minimal access surgeon should
give a chance to the newborn the advantage of this
approach. The outcome is comparable if you TREAT
these babies well.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
124 Journal of Indian Association of Pediatric Surgeons / Jul-Sep 2016 / Vol 21 / Issue 3
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