Thoracoscopic Aortopexy for Pediatric Tracheomalacia: Refining Technique Through Early Experience.

Aortopexy is the most common surgical intervention for pediatric tracheomalacia (TM). The thoracoscopic approach, despite being reported by a few authors, remains controversial due to the different reported techniques and outcomes.We report a retrospective review of our preliminary experience with thoracoscopic aortopexy from 2023 to date. Patients' demographic data and symptoms were collected: age and weight at surgery, comorbidities, presence of brief resolved unexplained event (BRUE), dyspnea, chest infections, and barking cough. The study describes our surgical technique and its evolution. We analyzed the clinical outcome and endoscopic improvement, success and complication rate, operative time, and length of stay. We then compared our findings with the results of open and thoracoscopic aortopexy reported in the current literature.A total of 12 thoracoscopic aortopexies were performed on 10 patients (including two redo). The mean age and weight at operation were 3.2 years (range: 4 months-6 years) and 13.6 kg (range: 3.5-23), respectively. Two patients presented with BRUE, one with dyspnea, in the other cases the indications were recurrent pneumonia (more than six per year or three in 6 months). All patients underwent preoperative flexible bronchoscopy for the diagnosis of TM. The average estimated tracheal collapse was 86% (range: 70-95%). One intraoperative bleeding caused a conversion to open surgery, but no other complications occurred. All patients were extubated on the same day. Two cases required a redo due to suture tearing, and one of them required an additional posterior tracheopexy for persistent symptoms. The remaining patients had significant improvement on follow-up: success rate is 75%. Both patients requiring redo underwent aortopexy without pledgeted sutures or innominate artery (IA) suspension: these steps are associated with a success rate of 88.9% (p = 0.0182). Our refined technique now includes total thymectomy, pericardiotomy, pledgeted horizontal mattress sutures on the aorta, and the IA after full mobilization of the innominate vein.Thoracoscopic aortopexy appears to be a feasible and effective option for pediatric TM, particularly when replicating open surgical principles. Further research is needed to optimize the technique and improve the clinical results.