Suspension Sutures for Complex Neonatal Anastamoses

Abstract

Introduction: Complex neonatal congenital defects pose a challenge for surgical repair utilizing minimally invasive techniques. We demonstrate a technique using suspension stitches to facilitate the thoracoscopic repair of esophageal atresia and laparoscopic repair of duodenal atresia. We detail the placement of a stitch that suspends the anastomosis. This lifts the surgical field up to facilitate visualization, provides a dynamic source of traction, and minimizes instrumentation of delicate tissue. Methods: Esophageal atresia: a 1-day-old 2900 g baby boy presented with an aberrant right subclavian artery, a left-sided aortic arch, proximal esophageal atresia, and distal tracheoesophageal fistula. Preoperative chest radiograph demonstrated a short gap. In the operating room (OR), he was placed on high-frequency oscillator ventilation and positioned in the exaggerated left lateral decubitus position (nearly prone). A thoracoscopic approach was used with a 3-mm equipment, ligating and dividing the azygous vein and tracheoesophageal fistula in standard fashion. A 4-0 absorbable, monofilament suture was placed through the chest wall near the spine, through the proximal pouch, through the distal esophagus, and back out the chest wall to bring the two ends of the esophagus together. This suspension stitch facilitated completion of the anastomosis with good visualization and minimal manipulation of the tissues. An 8F feeding tube was guided through the anastomosis and a 12F chest tube placed into the right hemithorax. Duodenal atresia: a 2-day-old 2700 g baby girl presented with trisomy 21, balanced AV canal, duodenal atresia, and annular pancreas. A radiograph demonstrated a double bubble with no distal gas. In the OR, she was intubated and positioned supine. A laparoscopic approach was used with the 3-mm equipment, first confirming normal rotation and identifying the proximal and distal ends of the duodenum with intervening annular pancreas. A 4-0 braided, absorbable suture was placed through the abdominal wall near the fundus of the gallbladder, through the proximal duodenum, through the distal duodenum, and back out the abdominal wall to bring the two ends of the duodenum together. This suspension stitch facilitated completion of the anastomosis with good visualization and minimal manipulation of the tissues. Results: Operative time for thoracoscopic esophageal atresia repair was 90 minutes. Nasogastric feeds were initiated with return of bowel function. An esophagram on postoperative day 5 showed no leak. Oral feeds were started and the thoracostomy tube removed. Repeat esophagram at 1 year showed no stricture. Operative time for laparoscopic duodenal atresia repair was 120 minutes. Feeds were initiated on postoperative day 7, once orogastric tube output had decreased. Conclusion: We demonstrate use of suspension stitches to line up difficult anastomosis. This technique is useful in a variety of settings and accomplishes the aforementioned goals of lifting the surgical field into view, provides traction that can be tightened/loosened as necessary, and minimizes tissue handling in this fragile patient population. Using this technique, we are able to routinely repair these congenital defects in neonates weighing as little as 1.7 kg. Suspension stitches provide another innovative method to build reproducible success in dealing with these difficult congenital anomalies. The authors have no relevant financial disclosures. Runtime of video: 5 mins