52: Minimally Invasive Techniques for Esophageal Repair

Introduction

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.

Esophageal Atresia with and without Tracheoesophageal Fistula

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