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Hi, I'm Emgody from Cincinnati Children's Hospital Medical Center.

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And last year in October 2022, Cincinnati Children's hosted the Quad Conference,

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which was a combination of four conferences.

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The International Organization for Isophagal Atresia,

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the Aerodigestive Society Conference, the Cincinnati Children's Airway

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Course and the Cincinnati Children's Pediatric Dysphagia Series.

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And today we're going to review

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the Theracoscopic Tracheopexy and Orthopexy for Tracheomalacia

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with Dr. Erin Garrison.

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Several years ago, our approach was that comers with tracheomalacia

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would undergo orthopexy.

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However, in the last 45 years, it's becoming standard practice to determine

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which patients will respond best to the tracheopexy versus orthopexy.

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But first, let's hear why it's important to repair tracheomalacia.

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I think some of us who are Pete surgery trained were told initially that

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tracheomalacia is something that kids will grow out of and will get better.

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And as data has shown recently that there's now long term consequences

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for swelling into the lungs and having chronic lung aspiration.

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And over time, that really is detrimental.

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Knowing which kid will benefit from a tracheopexy or an orthopexy

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is a little more challenging.

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So how do we determine which procedure is best for each patient?

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Preoperative Dynamic Reconstruction Studies gives us a lot of information.

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This is inspiratory and expiratory films from a patient

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we were evaluating for an aortapexy.

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And this is the same airway with expiration.

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You really see what you need to see with the dynamic studies.

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Part of the workup is making sure that there is space to anteriorly

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suspend the aorta so that you actually can make the trachea diameter larger.

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So we always look for the thymus and make sure that there is enough tissue

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to remove to be able to bring the trachea up anteriorly.

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Preoperative Bronchoscopy gives the surgical team an idea of internal anatomy,

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which can assist in classifying the degree of tracheomalacia

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prior to surgical intervention.

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You can really see how the membranous trachea bulges posteriorly.

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Our classification system is in evolution and trying to describe

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what is mild or severe or moderate is a little bit challenging.

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Now that we determined which procedure that patient needs,

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let's talk about the advantages and disadvantages of a minimally invasive

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trachoscopic approach as opposed to an open approach.

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The benefits of minimally invasive, to me the biggest one is that visualization and exposure.

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Disadvantages, takes longer to learn, it's more uncomfortable to learn,

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and your anesthesia colleagues sometimes are a little bit hesitant to allow cases

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to go on a little bit longer, especially the thoracoscopic cases.

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Historically, there were concerns that longer cases can lead to metabolic derangements,

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causing the patients to become more esodotic.

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Is that still the case? What exactly are the concerns of the anesthesia team?

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This is a paper out of anesthesiology that looked at open, thoracoscopic,

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and then converted patients and just looked at blood gases

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and metabolic derangements during the surgery, and there's really no difference

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whenever they checked the gases.

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Same thing when they looked at blood pressure with acidosis and hypoxia.

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Next, positioning the patient.

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When using a thoracoscopic approach, correct positioning is the key to success.

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It's best to use gravity to your advantage as it aids in retracting the lungs and your trache replacement.

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If you're working in the anterior mediastinum, this is how we position the babies with the arm up

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and a bump underneath so that you have access to the axilla and anteriorly.

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Positioning is set and trocars are placed.

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The surgeon can begin the procedure.

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Here, Dr. Garrison describes his approach to aorta pexy.

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We're going to briefly touch on aorta pexy.

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The goal is to spin the aorta.

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Our first step is taking out the thymus, finding the aorta anomic junction,

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and then identifying the arch of the aorta, which is here.

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Next is opening the pericardium.

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And this is really the key point, finding the area at the pericardial adventitial junction to suspend.

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If you go up too high, then you're doing a pericardial pexy,

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and it isn't quite as successful or durable.

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I think suture, transternally, is preferred with this approach,

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though it can be technically difficult.

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And for a tercopexy, a posterior approach via semi-pronged position is preferred.

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Here, you need to create a pneumothorax by putting the virus off of the tip of the scapula,

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which helps collapse the lung for trocar placement.

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When operating here, triangulating your hands gives the best visualization and working space.

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The goal of a posterior tracheopexy is taking that anterior spinal ligament and fixing it to

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the posterior membranous trachea.

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That area of floppy membrane is distal to that dilated pouch, usually.

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When available, a multidisciplinary team, which includes a pulmonologist,

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can allow for internal visualization via bronchoscopy.

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This technique is primarily used in non-osophageal atresia patients.

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We can make an indent on the posterior wall of the trachea, and they can see it pop up on their

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bronchoscopy and help us guide that.

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This is a patient who we are talking about doing that tracheopexy at the time of EA repair,

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and you can really see the trachea here just bulging with denolation.

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That proximal pouch is hidden up there.

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The next step is to determine the best location to place sutures and where the esophagus will lie

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once the pexie is completed.

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I'm trying to figure out where is that esophagus going to go as you pexie the posterior wall of

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the trachea to that anterior spinal ligament.

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It usually takes about two or three sutures, leaving enough space for that esophagus to come

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through.

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I do like using the knot pusher in a tension suture, I think it is helpful.

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It's important to create enough tension in the suture to ensure that pexie is secure.

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This is the part that I think is honestly the hardest, getting that suture to roll through the

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anterior spinal ligament is actually pretty challenging.

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And our approach changes if it's for a patient without esophageal atresia or an esophagus in

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continuity.

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This time the first step is to dissect around the esophagus.

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Using a vessel loop for retraction is a helpful technique.

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There are times where we put the esophagus to the left of the trachea and there are times where we

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put the esophagus to the right of the trachea.

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I always worry a little bit about dysphasia but honestly it's not something that I've seen a ton

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Using pre and post-operative bronchoscopy allows the surgeon to see the improvement prior to case

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completion.

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You can see how much intrusion on the posterior trachea there is at the beginning of the case and

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then afterwards at different levels it looks much better.

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In summary, both aorta-pexy and tracheophexy are beneficial to patients suffering from tracheomalacia.

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It's important to obtain preoperative dynamic studies to determine which procedure is best suited

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for each patient.

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In this video we've briefly reviewed both procedures through a minimally invasive

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tracheoscopic approach and are excited to see future data regarding best practices for

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determining who can benefit from these procedures and standardization of the approach.