Minimal access extrapleural esophagoesophagostomy

Background/purpose Minimal access repair of esophageal atresia is gaining acceptance but usually requires a transpleural approach. An extrapleural approach using a 2-cm incision has been described. The purpose of this study was to develop a less-invasive approach to extrapleural esophagoesophagostomy. Methods A 5-8 kg nonsurvivor piglet model was used to develop this technique. The extrapleural dissection was performed under direct vision utilizing transpleural thoracoscopy. A 16-gauge needle and a spatula were used to create an extrapleural space that allowed insertion of a 3-mm trocar. An 8F catheter with a 3-mL balloon was inserted through the trocar and inflated to create enough space to exchange it for a 5-mm trocar. A 12F catheter with a 5-mL balloon was inserted through the 5-mm trocar and inflated to enlarge the space. These steps were repeated at each of the 3 extrapleural port sites until one confluent extrapleural space was created that did not communicate with the transpleural port site. Esophagoesophagostomy was then completed within the extrapleural space. Results Thoracoscopic guidance and balloon dissection facilitated creation of an adequate extrapleural working space. Conclusions This new minimal access extrapleural approach offers an attractive alternative to the currently described minimal access approaches to esophagoesophagostomy.