52: Minimally Invasive Techniques for Esophageal Repair

While minimally invasive techniques have been used to alleviate esophageal symptoms, such as thoracoscopic release of vascular rings causing esophageal obstruction or laparoscopic fundoplication for gastroesophageal reflux disease (GERD), this chapter focuses on minimally invasive methods for direct surgical repair of congenital esophageal anomalies: esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) and foregut duplication cysts.

As described in the previous chapter, the advent of successful surgical intervention for EA in the 1930s and 1940s was a hallmark event for pediatric surgery, changing a universally fatal anomaly into one that could be surgically repaired with an expectation for long-term success. With the development of minimally invasive techniques and the rapid advance of both supporting technology and surgical skill and experience, thoracoscopic approaches to esophageal repair have been proposed. Since the first report of a primary thoracoscopic repair of congenital EA in 1999 and EA with TEF in 2000, the use of this technique has gained traction and now is being performed at many, if not most, centers with advanced pediatric surgery capabilities.¹

The novelty of reports describing the thoracoscopic technique for repair of EA/TEF, not to mention that the operation is performed on some of our most fragile patients, is likely responsible for the delay in widespread acceptance of this approach. It ranks among the most technically demanding of pediatric minimally invasive procedures and requires advanced thoracoscopic surgical skill.^1,2 Multiple centers, however, now have reported their experience with this approach to treating EA with or without TEF, and as experience and longer-term outcomes accumulate, its place in the field of pediatric surgery will be determined.

On the other hand, the excision of foregut duplication cysts, specifically esophageal duplication cysts, is particularly suited to minimally invasive techniques, and this procedure now is routinely performed thoracoscopically. In contrast to newborns with EA in all its various forms, patients with foregut duplication cysts generally are older, more healthy, and rarely present with comorbid conditions. The absence of comorbidity perhaps is most responsible for the ready acceptance of the thoracoscopic approach to excising foregut duplication cysts.

EA occurs in 1 in 5000 births. It can develop in many forms, with the most common being the “Type C” atresia, comprised of EA with a distal TEF (see Fig. 52-1). The second most common scenario is EA without TEF, so-called pure EA. Although other forms exist, these two forms are most amenable to the thoracoscopic approach to esophageal repair. Since the first reporting of thoracoscopic repair of pure EA in 1999³ and EA with distal TEF in 2000,⁴ this approach has become increasingly used, and multi-institutional experiences have been reported.¹

General Principles

As with any intestinal anastomosis, the key surgical principle of the thoracoscopic esophageal repair in EA is to perform the procedure with the same high standards as one would follow when performing open surgery. Paramount in this procedure is healthy tissue, placed together with minimal tension. Some technical principles are detailed below, but are highlighted by the need to handle tissue gently and to incorporate sturdy, full-thickness bites including mucosa into the anastomosis without creating undue tension. As with all minimally invasive techniques, ergonomics and surgeon comfort during the procedure are important to prevent fatigue and allow for fine, delicate movements in the dissection of fragile structures. In addition, although we tend to use intracorporeal knot-tying techniques, extracorporeal techniques using a knot pusher are also well described. Finally, although the surgical techniques may be modified, it is paramount that the surgeon not compromise the quality of the operation to achieve a successful minimally invasive procedure.

The key clinical characteristic that defines thoracoscopic surgery, in antithesis to its open counterpart, is the significantly reduced morbidity related to the incision(s). In the immediate postoperative period, the drastically reduced pain associated with thoracoscopic surgery allows for faster recovery and decreased pulmonary complications in children who may already be at risk for other conditions such as congenital cardiac disease (see below). In addition, patients, especially newborns, are at particular risk for sequelae of open thoracotomy, including musculoskeletal deformities such as “winged” scapula, muscular atrophy with resultant asymmetry, and/or scoliosis.¹

Timing of surgery depends on the patient's underlying diagnosis (pure EA vs. EA/TEF) and their stability. Pure EA patients can undergo thoracoscopic repair in a delayed fashion, after initial tube gastrostomy and a period of growth on enteral nutrition. Patients with EA/TEF are generally repaired within the first 24 hours of life assuming appropriate size, hemodynamic stability, and the absence of more pressing concomitant congenital defects.

Preoperative Assessment and Patient Selection

Since the various forms of EA can all be a component of the VACTERL (Vertebral anomalies, Anorectal anomalies, Cardiac defects, Tracheo-Esophageal anomalies, Renal anomalies, Limb defects) association, appropriate screening tests should be performed on all patients found to have EA. These include echocardiogram, spine ultrasound and plain films, and renal ultrasound. Chief among these, and the only one necessary prior to operative intervention for EA/TEF, is the echocardiogram. This allows for identification of intracardiac defects, such as ventricular septal defects or tetralogy of Fallot, and for identification of a potential right-sided aortic arch. In most cases, the surgical approach for repair of EA/TEF is through the right chest. A right-sided aortic arch, however, will prompt most surgeons to change to the left chest. Another common association involving EA is the cleverly but somewhat incompletely named CHARGE syndrome (Coloboma, Heart defects, choanal Atresia, Retardation, Genital hypoplasia, Ear abnormalities). This diagnosis is often made postoperatively, and may affect long-term outcomes.

While hemodynamically unstable patients and very premature or growth restricted newborns (<1500 g) should likely not undergo thoracoscopic repair of EA/TEF, there are other relative contraindications. These include significant congenital heart disease and smaller infants (less than 2.5 kg). One additional feature which should be assessed is the expectation of relative “gap” between the proximal esophageal pouch and the fistula in TEF or the distal pouch in pure EA. Plain films can help determine the location of the proximal pouch, with its coiled nasogastric tube, and obviously, the presence of a distal fistula based on the presence of bowel gas. Meanwhile, bronchoscopic evaluation can assess the level of the fistula (e.g., location relative to the carina). In cases of pure EA, most patients receive a gastrostomy at birth followed by delayed esophageal repair. In these cases, a preoperative gap assessment can be obtained by placing a radiopaque instrument such as a Bakes dilator via the gastrostomy and transorally, and obtaining fluoroscopic imaging while placing moderate pressure on the dilators. This technique can also be used intraoperatively for easy identification of the esophageal ends.

Each individual patient's qualifications for a thoracoscopic approach must be assessed using a combination of these multiple variables. As surgeons (and anesthesiologists) gain more experience and confidence, these boundaries will continue to be tested.^1,5

Technique

Evaluation of the Fistula

We prefer to perform rigid bronchoscopy on all children with suspected EA (see Fig. 52-1), to identify and locate the TEF and also to potentially control it with the use of a balloon-tipped catheter which can be lodged within the proximal fistula and allow for the safer administration of positive-pressure ventilation during the initial stages of anesthesia prior to operative control of the fistula. While this is our chosen technique, not all surgeons perform this step.

Rigid bronchoscopy requires cervical extension in the supine position and the gentle use of an appropriately sized rigid ventilating bronchoscope. Important findings to note should include the assessment of vocal cord function for documentation prior to potential surgery on and around the vagus nerves, assessment for location of the distal fistula, a thorough and methodical evaluation of the posterior membranous trachea to rule out the possibility of multiple TEFs, and the assessment of tracheal stability with the presence or absence of significant tracheobronchomalacia. We then place a Fogarty-type balloon catheter transorally and bronchoscopically direct it into the fistula, inflating the balloon just inside the fistula itself. At the conclusion of bronchoscopy, the patient is orotracheally intubated with the goals of maintaining spontaneous ventilation if possible and avoiding intubation of the fistula which could result in disastrous decompensation. All of these steps are similar for both the open and thoracoscopic techniques.

Anesthetic Considerations and Lung Isolation

The anesthetic technique employed and full two-way communication between the anesthesia and surgery teams are essential to the successful completion of a thoracoscopic procedure in a neonate.¹ The team must be efficient to limit anesthetic time, limit time on positive-pressure ventilation prior to fistula control and maximize the amount of work accomplished during (essentially) single-lung ventilation.

Neonates with pure EA or EA/TEF typically undergo inhalational induction followed by bronchoscopy and balloon control of the fistula. Appropriate IV access is then obtained, typically in the form of 2 to 3 peripheral intravenous catheters and an arterial line for both monitoring of blood pressure and access to obtain blood for laboratory measurements. Transfusion intraoperatively is generally not warranted, and most patients are provided with hourly maintenance isotonic solution as well as 20 to 40 mL/kg of intravenous fluid boluses. Patients have safely been maintained on neuromuscular blockade without significant risk of gastric overdistention, even without preoperative balloon control of the fistula.⁶ Orotracheal intubation usually suffices, though some practitioners will attempt blind or fiberoptic-guided left mainstem intubation. Adequate lung deflation can be achieved by gentle carbon dioxide (CO₂) insufflation using a low flow (1 L/min) and low pressures (4–5 mm Hg).⁵

One key physiologic point is the expected immediate decompensation upon entry into the chest, when the patient is subjected, essentially, to single-lung ventilation. The anesthesia and surgery teams should expect relative hypoxia and hypercarbia, which are usually transient and recover within minutes as intrinsic physiologic mechanisms compensate for the loss of ventilation in the lung on the operative side and thus recover more normal matching of ventilation and perfusion. The frequent evaluation of blood gas measurements will allow for monitoring of this trend. In addition, should the patient not tolerate CO₂ insufflation or lung retraction, both of these may be reversed instantaneously by the surgeons to allow the anesthesiologist to recruit the lung and improve the patient's status. Ultimately, the free-flowing discussion between the surgeons and anesthesiologists allows for ongoing decision-making regarding proceeding with thoracoscopic repair or converting to an open approach.

Positioning of Patient and Port Placement

Following bronchoscopy and anesthetic preparation, most surgeons prefer a modified prone position (see Fig. 52-2), with the patient's right chest elevated 45 degrees. This positioning allows the lung and anterior mediastinal structures to fall anteriorly with gravity retraction, thus giving the surgeon excellent exposure to the posterior mediastinum, airway, and esophagus.

With this positioning, the surgeon and assistant stand on the anterior side of the patient, while the monitor is placed at eye level on the posterior side of the patient alongside the scrub nurse.

Three access sites are necessary for the procedure. An initial camera port (generally 4 mm) is placed just inferoposterior to the scapula, usually coinciding with the fifth intercostal space. We use a cut-down type approach, making an appropriate skin incision followed by blunt dissection above the rib using a straight Jacobson dissector. Lung ventilation is held when the pleura is encountered and the pleural space is entered bluntly. The chest wall defect is dilated to the appropriate size and the 4-mm trocar inserted. We use metal trocars fitted with a sleeve (a cut portion of an 18Fr red rubber catheter), which is sewn to the skin to prevent trocar migration.

Two additional ports are placed under direct visualization (Fig. 52-2). One is placed 1 to 2 intercostal spaces above the first port, and more in the midaxillary line (this generally falls in the middle of the axilla). If endoclips are to be used to control the TEF, this should be a 5-mm port. The 5-mm port also has the benefit of allowing for direct passage of suture with needles (e.g., 5-0 Vicryl or PDS on a TF needle). Otherwise, if ligature control is to be used, a 3- or 4-mm port may be used and suture passed directly through the chest wall when necessary. The third port, usually 3 mm, is placed 1 to 2 intercostal spaces below the first port, in the posterior to midaxillary line. Ideally, the second and third trocars placed, corresponding to the right and left hand working ports, will allow for the instruments to meet at a right angle at the level of the fistula and anastomosis.^5,7 Should gravity and CO₂ insufflation not provide adequate exposure, additional lung retraction can be achieved by the placement of another trocar or stab incision inferiorly for the use of an instrument by the surgical assistant solely for anterior lung retraction.

Identification and Ligation of the Fistula

Upon port placement, CO₂ insufflation is achieved and the posterior pleural space should be readily visible. The azygos vein is identified, mobilized with blunt dissection and generally sacrificed either with hook cautery or division between ties (Fig. 52-3). Ligation and division of the azygos makes the underlying distal esophagus readily evident (Fig. 52-4). In cases of EA/TEF, this usually corresponds to the entry of the fistula into the membranous portion of the trachea just above the carina. The excellent view through a surgical telescope generally makes identification of the distal esophagus easy. For EA/TEF, blunt and sharp dissection with the use of curved dissectors and laparoscopic scissors are used to follow the fistula to its entry into the posterior trachea where the fistula can be ligated using an endoclip or ligature. During this dissection, care is taken to avoid injury to the vagus nerve. Ligation flush with the trachea is important to prevent formation of a tracheal diverticulum which could pool secretions and lead to soiling of the lungs in the future. Once ligation of the fistula is achieved, the “pressure is off” in terms of concern regarding the use of positive-pressure ventilation and the risk of gastric overdistention. Prior to division of the fistula, it is sometimes useful to mobilize the upper esophageal pouch to prevent retraction of the distal esophageal pouch prior to creation of the anastomosis.

Identification and Mobilization of the Proximal Esophageal Pouch

With the anesthesiologist placing pressure on the nasogastric tube, the proximal esophageal pouch is evident (Fig. 52-5). Blunt and sharp dissection with judicious electrocautery can be used to then free the proximal pouch all the way to the thoracic inlet. The surgeon should work on all sides simultaneously, though always saving the dissection of the common wall with the trachea for times when maximal tension is evident due to dissection of the other sides. This common wall is typically dissected sharply with some electrocautery if needed. Some surgeons prefer to place a traction suture through the distal tip of the pouch to provide a sturdy handle for manipulation of the proximal pouch during this dissection.

Anastomosis

At this point, traction on the proximal pouch should be able to demonstrate the ability to achieve an adequate primary anastomosis under minimal tension. If not, additional dissection of the proximal and/or distal pouch may be warranted. Most surgeons prefer to limit the dissection of the distal esophagus, if possible, to avoid dissection of the esophageal hiatus and gastroesophageal junction. Patient anatomy will dictate the amount of dissection necessary, whereas surgical judgment will determine what level of tension is necessary and allowable before considering other methods of esophageal reconstruction should anastomotic tension be unacceptable. In cases of pure EA, dissection of the distal esophageal pouch is nearly universally necessary. In general, if the esophagus can be brought together, even under tension, this is advisable and preferable to any other method of esophageal reconstruction. Tension, while not ideal, is acceptable in order to achieve a primary esophageal anastomosis. If significant tension exists, the use of slipknots to gradually bring the anastomosis together and help distribute the tension has been found helpful.^8,9

Once anastomosis is feasible, the fistula can be divided distal to the clip or tie, leaving a small cuff. The proximal pouch can be incised, though we prefer to remove a circular portion of the distal tip to allow for an adequate anastomosis. The anastomosis is then created using absorbable braided or monofilament suture, at the surgeon's discretion. In general, 5-0 suture is advisable in newborns, on a small taper needle such as a TF. This portion of the procedure requires advanced thoracoscopic and intracorporeal suturing techniques, and its success is dependent on previously well-positioned trocar placement.

After the placement of a corner stitch, the posterior wall of the anastomosis is performed first, using simple interrupted stitches with the knots in an intraluminal position. To prevent tearing of the often thin esophageal wall, adequate tissue must be incorporated. Mucosa must be incorporated in every bite. Once the posterior wall is fashioned, most surgeons use a transanastomotic feeding tube (6Fr or 8Fr), placed by the anesthesiologist transnasally and guided into the distal esophagus and stomach thoracoscopically (Fig. 52-6).

The anterior wall is then fashioned in the same manner, with the transanastomotic feeding tube allowing for large bites without concern for incorporation of the posterior wall of the esophageal lumen. After completion of the anastomosis (Fig. 52-7), hemostasis is verified.

Completion of Procedure

An air leak test can be performed by instilling a small amount of saline, retracting the lung, and asking for a Valsalva maneuver from the anesthesiologist while visualizing the tracheal fistula tie or clip. If desired, some viable tissue (e.g., end of azygos, pleural flap) can be placed between the esophagus and trachea to reinforce the fistula ligation and help prevent recurrence of the TEF. Alternatively, a piece of treated bovine pericardium may be used as a biologic barrier to prevent reformation of the TEF and can be placed between the esophageal suture line and the clip/ligature on the tracheal side of the fistula ligation (Fig. 52-7). A 12Fr chest tube can then be placed through the left hand working port site, positioned lateral to the anastomosis and secured to the skin. The lung is then observed to inflate during normal breathing to verify no injury to the trachea or right mainstem bronchus, and the ports are then removed. Local anesthetic can be administered at the start or finish of the case. The incisions are closed with small absorbable sutures for the muscular fascia, deep dermal and subcuticular layers and sterile dressings are applied. The chest tube is generally placed to low suction (–10 cm H₂O).

Postoperative Management

The patient is generally left intubated and slowly weaned from the ventilator over the next day or several days. In cases of significant anastomotic tension, additional precautions may be taken, including longer-term sedation and even paralysis to prevent additional tension from being placed on the anastomosis.⁹ Care must be taken to avoid aggressive endotracheal suctioning which could injure the recently dissected trachea or dislodge the controlling clip or ligature on the fistula. In addition, should reintubation be required, it should be performed by a practitioner familiar with the anatomy involved and cognizant of the risks of both deep tracheal intubation and accidental esophageal intubation. Many surgeons have horror stories of disrupted tracheal or esophageal suture lines as a result of unfortunate events during emergent reintubation.

Feeding via the nasogastric tube is based on surgeon preference. All patients are placed on aggressive acid-reducing regimens, usually at a maximal dose of proton pump inhibitors. The high incidence of gastroesophageal reflux, coupled with esophageal dysmotility and injury to the anastomosis from refluxed acid, make this an important adjunct therapy.

Chest tube output is monitored for the possibility of lymphatic leak or for evidence of oral secretions which would be concerning for anastomotic leak. An esophagram is obtained, usually around postoperative day 7. If no leakage is demonstrated, oral feedings can be initiated and the chest tube can be removed. Evidence of leak is usually localized or controlled by the chest tube, in which case a repeat contrast study can be obtained after another week to assess for seal of the leak which will occur in most cases.

Outcomes and Complications

Though pediatric surgeons are relatively early in their experience with thoracoscopic repair of EA and TEF, short-term outcomes reported by centers known for excellence in minimally invasive surgery are encouraging. One notable report of 104 patients, involving several centers from multiple countries, outlines a success rate of thoracoscopic repair of nearly 95%. Complications in these patients included leak (8%), stricture (4%), and recurrent fistula (2%). Nearly 32% of patients required at least one esophageal dilation. Three patients died in this series, two from unrelated causes and one from tracheal fistula closure disruption during reintubation.¹ These outcomes are remarkably similar to those obtained in similar series of patients repaired through open thoracotomy. Long-term follow-up of these patients will allow for comparison of musculoskeletal complications which may demonstrate a significant benefit of the minimally invasive technique.

Important in the interpretation of these data, however, is the fact that the minimally invasive series represents the work of surgeons skilled in very high-level minimally invasive surgery. They noted a significant learning curve and the need for surgical expertise in performing this operation thoracoscopically.

Summary

Thoracoscopic repair of EA and TEF is feasible in most patients with standard anatomy, with outcomes similar to open repair when performed by skilled minimally invasive surgeons. As experience with this technique grows, and a new generation of surgeons is trained in advanced minimally invasive techniques, this will likely become a routine procedure in the armamentarium of the pediatric surgeon.

Foregut duplication cysts occur as a mishap of the normal ventral budding process of the lung primordium off the foregut. Their location as posterior mediastinal cystic structures usually results in symptoms of recurrent respiratory problems such as cough or wheeze (usually in the case of bronchogenic cysts) or partial esophageal obstruction resulting in feeding difficulty or dysphagia (in the case of esophageal duplication cysts). As abnormalities of development, these lesions do not regress, and surgical excision is therefore required to prevent or treat these symptoms. Reports of malignant degeneration lend additional credence to the practice of routine surgical excision.

General Principles

The thoracoscopic excision of foregut duplication cysts has become relatively routine as overall surgical experience and comfort with thoracoscopy in young children continues to grow. In contrast to patients with EA, patients undergoing surgery for foregut duplication cysts are generally larger and older and have less comorbidities. This makes the preoperative comfort level with thoracoscopy that much higher. Nonetheless, thoracoscopic surgery in these cases involves the use of advanced minimally invasive techniques, including suturing in a tight space to repair the esophagus or close a hole in the airway, such that a high level of surgical skill is still warranted before undertaking these procedures.

Preoperative Assessment and Patient Selection

As mentioned, most patients with these lesions are relatively healthy and can tolerate thoracoscopy well. If significant airway obstruction is present resulting in overinflation of one or the other lung, visualization may be impaired and thoracotomy may be required. Likewise, if inflammatory changes from infection of the lesion make resection significantly difficult, conversion to an open procedure may be warranted.

Otherwise, most patients are candidates for thoracoscopic resection. Preoperative imaging with chest computed tomography helps to identify the lesion and plan the procedure. In the case of esophageal duplication cysts, an esophagram may be of use to determine the nature of the lesion's relationship to the esophageal lumen. In most cases, these cysts are located within the muscular wall of the esophagus, sharing a common wall with the esophageal lumen.

Technique

Anesthetic Considerations and Lung Isolation

Almost all cases will be approached through the right chest, though ultimately preoperative imaging may lead the surgeon to choose the left side instead. This is usually in the case of carinal bronchogenic cysts that may be affecting the left mainstem more than the right. Most patients benefit from anesthetic lung isolation. If a double-lumen endotracheal tube is not feasible due to patient size, a bronchial blocker can be used to isolate the right lung. In addition, CO₂ insufflation during the procedure will assist with compression of the lung. Peripheral intravenous access and a monitoring arterial line are used. In addition, an appropriate sized esophageal bougie is used in the case of esophageal duplication cysts to help with dissection of the cyst and its common wall with the esophageal mucosa and with identification of possible esophageal perforation during the procedure.

Positioning of Patient and Port Placement

Similar to the EA repair, the patient is placed in a modified prone position, with the right chest elevated approximately 45 degrees. Again the surgeon and assistant both stand to the anterior side of the patient. An initial, usually 5 mm, port can be placed in the axilla, in the mid- to posterior axillary line, and low-flow, low-pressure CO₂ insufflation instilled. Visualization of the lesion (Fig. 52-8) can then help to best place two additional ports in the mid- to anterior axillary line, with the aim to have the instruments meet at an approximate right angle at the lesion.

Cyst Excision

For esophageal duplication cysts, the esophagus and cyst are mobilized by incising the overlying pleura and using a combination of blunt and sharp dissection with judicious electrocautery. The esophageal muscular wall is split bluntly and the cyst raised out of the muscular wall in a submucosal plane (Fig. 52-9). Performing the entire dissection off the muscular wall before then finally dissecting the common wall with the esophageal mucosa maximizes the visualization during this more risky portion of the procedure. If the lumen is entered, absorbable suture is used to close the defect in an interrupted fashion. After excision of the cyst, we prefer to close the muscular wall, again using interrupted sutures (Fig. 52-10).

Excision of bronchogenic cysts is similar to that of esophageal duplication cysts. These lesions, however, are typically not within the wall of the airway and can be separately dissected free. They are often large and can be needle decompressed to assist with visualization, though leaving the lesion tense can sometimes assist with the dissection by helping to clearly delineate the cyst. These cysts often have a stalk connecting them to the airway, usually at the carina. This stalk should in general be ligated or sutured to assure satisfactory closure of the airway. Postexcision air test under saline can assist with identification of a residual air leak.

For any lesion in which a common wall exists, the dissection may be made safer by leaving the wall intact and stripping the cyst mucosa. Small mucosal remnants should be fulgurated. After excision, the cyst can be removed through the thoracoscopic ports, sometimes in pieces.

Completion of Procedure

Given the potential communication with the airway or esophageal lumen, a chest tube is left in place through one of the ports. The lung is observed to verify reinflation. After removal of the ports, the incisions are closed in layers with absorbable sutures, dressings applied, and the chest tube placed to suction drainage.

Postoperative Management

In general, the patients can be extubated in the operating room. Chest tube drainage is short-term, to verify no evidence of air leak or esophageal leak. For esophageal duplication cysts, if the esophagus required closure due to intraoperative perforation, an esophagram is obtained on postoperative day 5 to 7 to verify patency without leak and the chest tube is then removed and oral feeds resumed. Otherwise, the patient can be started on a soft diet on postoperative day 1 and discharged once routine discharge criteria are met. Many surgeons prefer to maintain the patients on a soft diet for several weeks to allow for satisfactory healing of the esophagus.

Complications

The complications associated with surgery on foregut duplication cysts include persistent air leak, or even bronchopleural fistula, and esophageal leak. Multiple single-institution series have reported acceptable rates of these complications for the thoracoscopic approach, in the 5% to 10% range.^10,11 In contrast, however, the length of stay for patients undergoing thoracoscopic surgery is days less than that of patients undergoing open thoracotomy.

Summary

Thoracoscopic resection of foregut duplication cysts has become relatively universal except in rare circumstances. Nonetheless, advanced minimally invasive techniques, skills, and comfort level are required on the part of the surgeon. Outcomes are favorable.

As expected, minimally invasive surgery continues to permeate the field of pediatric surgery. It is important for the adult surgeon to understand the congenital anatomy and the techniques of pediatric repair as these may impact surgery in unexpected manner. For example, I once operated on a patient with a large hiatal hernia who as a baby underwent a repair of coarctation of the aorta by Dr. Blalock. In the process of the dissection, I discovered that the celiac axis was at the level of the diaphragmatic hiatus as a consequence of the original surgery, thus complicating the repair. Furthermore, congenital defects that were not too symptomatic in childhood may present for therapy in adulthood requiring collaboration with pediatric surgeons for the best repair strategies.