Minimally Invasive Surgical Approach for Posterior Tracheopexy to Treat Severe Tracheomalacia: Lessons Learned from Initial Case Series.

Background/Purpose: Posterior tracheopexy directly addresses membranous tracheal intrusion in severe tracheomalacia (TM). We have previously reported our experience of posterior tracheopexy through open approach in a large series of patients. This study aimed to review lessons learned from our initial series posterior tracheopexy through the video-assisted or robotic video-assisted thoracoscopic approach. Methods: We retrospectively reviewed our single-institution experience on all patients who underwent video-assisted or robotic video-assisted posterior tracheopexy for treatment of symptomatic TM between October 2016 and February 2018. Results: Ten patients underwent video-assisted ( n  = 4) or robotic video-assisted ( n  = 6) thoracoscopic posterior tracheopexy (age range: 8 months-19 years). One patient, the youngest in our cohort, had a type C esophageal atresia repair; none of the other patients had undergone prior thoracic operations. All had symptomatic TM; 1 patient with tracheostomy dependence also had severe distal bronchomalacia, including segmental airways. Postoperatively, patients were hospitalized 3-7 days, with 1-2 days for ICU observation. Improved respiratory symptoms were noted in 9/10 patients following the operation. The 1 patient with preexisting tracheostomy had reduced ventilator dependence but remained hospitalized with ongoing respiratory symptoms. Conclusions: The thoracoscopic approach for posterior tracheopexy, while challenging, can be applied to a select cohort of children with severe TM. Thoracoscopic surgery with robotic assistance can eliminate some technical limitations of the video-assisted approach by providing an easier platform for more complicated suturing angles.