Thoracoscopic Division of a Vascular Ring in a Child

Contributors:Curt S. Koontz

This video details the thoracoscopic division of a vascular ring in a child presenting with dysphagia.  This is a safe and effective technique that minimizes the potential complications and cosmetic issues associated with a thoracotomy.

DOI#: https://doi.org/10.17797/ohknzpzkwi

Thoracoscopic Division of A Vascular Ring
Dysphagia and/or dyspnea with known vascular ring
Contraindications: -Inability to tolerate single lung ventilation Relative Contraindications: -Previous Thoracotomy
In an exaggerated lateral decubitus position (almost prone), a Veress needle is introduced into the left chest inferior to the tip of the scapula. Pulse oximetry monitors are placed on the upper extremities and a lower extremity to evaluate blood flow during test clamping of the left subclavian and ligamentum arteriosum. Using 5 mmHg of CO2, a pneumothorax is created. A 5mm trocar is placed for the camera. The working ports are placed relative to the mid-axillary line: a 5mm trocar posteriorly and a 5mm trocar anteriorly. An additional 2mm incision is placed for a Mini-step grasper (Stryker). Dissection of the pleura overlying the aorta is accomplished by electrocautery and blunt dissection. Structures to be identified during dissection of the vascular ring are the phrenic, vagus, and recurrent laryngeal nerves. A vessel loop is placed around the ligamentum arteriosum to facilitate clip placement. Division of the ligamentum is accomplished by using two 5mm Hem-o-lok clips (WECK, Teleflex Medical). A test clamp is performed prior to clipping. After division, esophageal adhesions are taken down bluntly, both proximally and distally to the vascular ring. An orogastric tube was placed to facilitate this dissection. Absorbable suture is used to close the deep layers and the skin incisions are closed with Dermabond (Ethicon, Inc.)
-Upper Endoscopy (identify mechanical obstruction) -Esophagram (confirmatory for obstruction, usually posteriorly) -CT angiogram of chest (evaluate for double aortic arch vs. right aortic arch with aberrant left subclavian) -Echocardiogram (if needed to evaluate double aortic arch or patency of ligatmentum arteriosum)
-Aorta is identified and location of the left subclavian is confirmed with test clamping -Ligamentum arteriosum is identified at the origin of the left subclavian -Recurrent laryngeal nerve identified as it loops around the ligatmentum arteriosum close to the pulmonary artery (screen left)
Advantages -Excellent visualization -Minimal post-operative pain -Tube thoracostomy generally not needed after procedure -Early post-operative discharge/return to normal activities Disadvantages -Requires advanced experience in minimally invasive techniques -Requires advanced anesthesia assistance for single lung ventilation in small children
-Pneumothorax -Post-operative hemorrhage -Hoarseness/dysphonia (injury to recurrent laryngeal nerve
Paul Twomey and John Stroud of Erlanger Audio-Visual Department with assistance in video creation

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