DOZ047.105: Minimally invasive surgical approach for posterior tracheobronchopexy to treat severe tracheobronchomalacia

Abstract

Abstract Purpose Posterior tracheobronchopexy directly addresses membranous airway intrusion in severe tracheobronchomalacia (TBM). Our experience of posterior tracheobronchopexy through an open approach in a large series of patients has been previously reported by us. This study aimed to review lessons learned from our initial series of posterior tracheobronchopexy through a minimally invasive surgical approach. Methods A retrospective review of all patients with symptomatic TBM who underwent video-assisted or robot video-assisted thoracoscopic posterior tracheobronchopexy between October 2016 and January 2019 was carried out. Results Fourteen patients underwent video-assisted (n = 4) or robotic video-assisted (n = 10) thoracoscopic posterior tracheobronchopexy (age range: 8 months–19 years). Two patients had a history of esophageal atresia (type C) repair; none of the other patients had undergone prior operations. Two patients required open conversion to achieve the desired precision of suture placement. Operative times ranged from 4.5 to 15 hours, depending on the additional procedures performed. The intraoperative bronchoscopic evaluation demonstrated marked improvement in airway patency of all patients at the conclusion of each case. Patients were hospitalized 2 to 7 days, with 0 to 4 days for ICU observation. One patient with bronchopulmonary dysplasia and diffuse TBM, including segmental bronchi, required longer hospitalization and prolonged mechanical ventilation support. Follow-up after surgery ranged from 1 to 27 months. Three patients required subsequent anterior aortopexy and tracheopexy. In these three cases, dynamic tracheobronchoscopy showed that posterior tracheopexy remained intact; nonetheless, anterior airway support was still required to prevent dynamic anterior airway collapse. Conclusions The thoracoscopic approach for posterior tracheobronchopexy, while challenging, can be applied in children with severe TBM. As experience is gained, more complicated procedures and reoperative cases are possible. The simultaneous use of flexible bronchoscopy is mandatory to confirm precision by providing luminal visualization during suture placement. Thoracoscopic surgery with robotic assistance can eliminate some technical limitations of the video-assisted approach by providing an easier platform for very complicated suturing angles.