Transthoracic single port with peroral assistance : an animal experiment to assess a less invasive technique for human esophageal atresia repair

Abstract

Thoracoscopic repair of esophageal atresia has becoming the gold standard in many centers since it allows a better cosmetic result and avoids the musculoskeletal sequelae of a thoracotomy. Natural Orifices Transluminal Endocopic Surgery (NOTES) is a new surgical paradigm and its human application was already started in some procedures. In the present study, we explore the feasibility to perform an esophago-esophageal anastomosis using a single transthoracic single port combined with a peroral access in a rabbit model to simulate repair of esophageal atresia by hybrid NOTES in a human newborn. Adult male rabbits (Oryctolagus cuniculus, n=28) were utilized to perform the surgical protocol. We used a transthoracic telescope with a 3 mm working channel and a flexible endoscope with a 2.2 mm working channel by peroral access. We performed total esophagotomy with peroral scissors followed by an esophago-esophageal anastomosis achieved with rigid transthoracic scope helped by peroral operator. Extracorporeal transthoracic knots were performed to complete anastomosis. The anastomoses were examined in loco and ex loco, after animal sacrifice. We successfully accomplished a complete esophageal anastomosis in all rabbits using a combination of transthoracic and peroral 3mm instruments. This study provides important insights for a possible translation of hybrid NOTES to human newborns with esophageal atresia. Forward studies to accomplish their feasibility in human newborns will still be necessary.