Hi, I'm Emgody from Cincinnati Children's Hospital Medical Center. And last year in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences. The International Organization for Isophagal Atresia, the Aerodigestive Society Conference, the Cincinnati Children's Airway Course and the Cincinnati Children's Pediatric Dysphagia Series.
And today we're going to review the Theracoscopic Tracheopexy and Orthopexy for Tracheomalacia with Dr. Erin Garrison. Several years ago, our approach was that comers with tracheomalacia would undergo orthopexy. However, in the last 45 years, it's becoming standard practice to determine which patients will respond best to the tracheopexy versus orthopexy. But first, let's hear why it's important to repair tracheomalacia.
I think some of us who are Pete surgery trained were told initially that tracheomalacia is something that kids will grow out of and will get better. And as data has shown recently that there's now long term consequences for swelling into the lungs and having chronic lung aspiration. And over time, that really is detrimental. Knowing which kid will benefit from a tracheopexy or an orthopexy is a little more challenging. So how do we determine which procedure is best for each patient?
Preoperative Dynamic Reconstruction Studies gives us a lot of information. This is inspiratory and expiratory films from a patient we were evaluating for an aortapexy. And this is the same airway with expiration. You really see what you need to see with the dynamic studies. Part of the workup is making sure that there is space to anteriorly suspend the aorta so that you actually can make the trachea diameter larger.
So we always look for the thymus and make sure that there is enough tissue to remove to be able to bring the trachea up anteriorly. Preoperative Bronchoscopy gives the surgical team an idea of internal anatomy, which can assist in classifying the degree of tracheomalacia prior to surgical intervention. You can really see how the membranous trachea bulges posteriorly. Our classification system is in evolution and trying to describe what is mild or severe or moderate is a little bit challenging.
Now that we determined which procedure that patient needs, let's talk about the advantages and disadvantages of a minimally invasive trachoscopic approach as opposed to an open approach. The benefits of minimally invasive, to me the biggest one is that visualization and exposure. Disadvantages, takes longer to learn, it's more uncomfortable to learn, and your anesthesia colleagues sometimes are a little bit hesitant to allow cases to go on a little bit longer, especially the thoracoscopic cases.
Historically, there were concerns that longer cases can lead to metabolic derangements, causing the patients to become more esodotic. Is that still the case? What exactly are the concerns of the anesthesia team? This is a paper out of anesthesiology that looked at open, thoracoscopic, and then converted patients and just looked at blood gases and metabolic derangements during the surgery, and there's really no difference whenever they checked the gases.
Same thing when they looked at blood pressure with acidosis and hypoxia. Next, positioning the patient. When using a thoracoscopic approach, correct positioning is the key to success. It's best to use gravity to your advantage as it aids in retracting the lungs and your trache replacement. If you're working in the anterior mediastinum, this is how we position the babies with the arm up and a bump underneath so that you have access to the axilla and anteriorly.
Positioning is set and trocars are placed. The surgeon can begin the procedure. Here, Dr. Garrison describes his approach to aorta pexy. We're going to briefly touch on aorta pexy. The goal is to spin the aorta. Our first step is taking out the thymus, finding the aorta anomic junction, and then identifying the arch of the aorta, which is here. Next is opening the pericardium. And this is really the key point, finding the area at the pericardial adventitial junction to suspend.
If you go up too high, then you're doing a pericardial pexy, and it isn't quite as successful or durable. I think suture, transternally, is preferred with this approach, though it can be technically difficult. And for a tercopexy, a posterior approach via semi-pronged position is preferred. Here, you need to create a pneumothorax by putting the virus off of the tip of the scapula, which helps collapse the lung for trocar placement.
When operating here, triangulating your hands gives the best visualization and working space. The goal of a posterior tracheopexy is taking that anterior spinal ligament and fixing it to the posterior membranous trachea. That area of floppy membrane is distal to that dilated pouch, usually. When available, a multidisciplinary team, which includes a pulmonologist, can allow for internal visualization via bronchoscopy. This technique is primarily used in non-osophageal atresia patients.
We can make an indent on the posterior wall of the trachea, and they can see it pop up on their bronchoscopy and help us guide that. This is a patient who we are talking about doing that tracheopexy at the time of EA repair, and you can really see the trachea here just bulging with denolation. That proximal pouch is hidden up there. The next step is to determine the best location to place sutures and where the esophagus will lie once the pexie is completed.
I'm trying to figure out where is that esophagus going to go as you pexie the posterior wall of the trachea to that anterior spinal ligament. It usually takes about two or three sutures, leaving enough space for that esophagus to come through. I do like using the knot pusher in a tension suture, I think it is helpful. It's important to create enough tension in the suture to ensure that pexie is secure.
This is the part that I think is honestly the hardest, getting that suture to roll through the anterior spinal ligament is actually pretty challenging. And our approach changes if it's for a patient without esophageal atresia or an esophagus in continuity. This time the first step is to dissect around the esophagus. Using a vessel loop for retraction is a helpful technique.
There are times where we put the esophagus to the left of the trachea and there are times where we put the esophagus to the right of the trachea. I always worry a little bit about dysphasia but honestly it's not something that I've seen a ton Using pre and post-operative bronchoscopy allows the surgeon to see the improvement prior to case completion.
You can see how much intrusion on the posterior trachea there is at the beginning of the case and then afterwards at different levels it looks much better. In summary, both aorta-pexy and tracheophexy are beneficial to patients suffering from tracheomalacia. It's important to obtain preoperative dynamic studies to determine which procedure is best suited for each patient.
In this video we've briefly reviewed both procedures through a minimally invasive tracheoscopic approach and are excited to see future data regarding best practices for determining who can benefit from these procedures and standardization of the approach.