Thoracoscopic Division Vascular Rings |
| Vascular
rings are congenital anomalies of the aortic arch system, resulting in
the formation of a complete or incomplete ring that compresses the
trachea, esophagus, or both, causing symptoms such as dysphagia,
respiratory distress, and chronic cough. Traditionally, these anomalies
were treated through open thoracotomy, but advancements in
thoracoscopic techniques have enabled less invasive interventions with
promising outcomes. Vascular rings are rare congenital anomalies resulting from aberrant development of the branchial arch arteries. The most common types of vascular rings include double aortic arches (DAA) and right aortic arch (RAA) with an aberrant left subclavian artery (LSCA) and ligamentum arteriosum. Symptoms typically arise in early childhood, although they can also present later, and may include airway compression leading to stridor and recurrent respiratory infections, or esophageal compression causing feeding difficulties and dysphagia. Thoracoscopic surgery has been introduced as a minimally invasive alternative to the traditional open thoracotomy approach. The thoracoscopic method involves dividing the vascular structure responsible for the ring, typically the ligamentum arteriosum or the non-dominant aortic arch, through several small incisions under video guidance. The initial reports on thoracoscopic division of vascular rings demonstrate favorable outcomes. One study reported one of the earliest experiences with thoracoscopic surgery in nine pediatric patients, all of whom were symptomatic prior to surgery. The study highlighted the safety and feasibility of the approach, noting no intraoperative complications and an average operative time of 107 minutes. Postoperatively, five patients experienced complete symptom resolution, while the rest showed significant improvement. The mean hospital stay was four days. Another study reviewed three cases involving a complete vascular ring, where patients showed immediate recovery post-surgery. The median operative time was longer (180.5 minutes), and complications such as chylothorax and vocal cord palsy were noted but resolved without long-term effects. This study suggested that thoracoscopic division of vascular rings may provide faster recovery times compared to traditional thoracotomy. Multiple studies have compared the thoracoscopic and open thoracotomy approaches for vascular ring division, highlighting key differences in operative time, recovery, and complication rates. One study compared outcomes in 200 pediatric patients who underwent either thoracoscopic or open surgery. Thoracoscopic surgery was associated with shorter hospital stays (1.2 days vs. 3.4 days) and fewer postoperative complications compared to thoracotomy. Both methods demonstrated excellent outcomes, with a freedom from reintervention rate of over 90% at 10 years. Another study also observed a reduced incidence of chylothorax, and shorter intensive care unit (ICU) stays in the thoracoscopic group. The study found complete symptom resolution in 71% of patients who underwent thoracoscopic surgery, compared to 63% in the open group. Furthermore, the thoracoscopic approach showed an advantage in terms of postoperative pain management and cosmesis. The standard thoracoscopic procedure involves placing the patient in a lateral decubitus position with single-lung ventilation to optimize visualization. Typically, three to four ports are inserted for instruments and the thoracoscope. Division of the vascular structure is usually achieved using vessel-sealing devices such as Ligasure or surgical staplers. Studies have emphasized the importance of careful preoperative imaging, often with computed tomography angiography (CTA), to precisely map the vascular anatomy and plan the surgery. Another report described long-term outcomes following thoracoscopic division of vascular rings in pediatric patients, with a median follow-up of 95 months. The study found that 88% of patients experienced symptom improvement, while the need for reintervention was minimal. This study highlighted the safety and durability of thoracoscopic surgery, even when KommerellÕs diverticulum was left untreated. Postoperative complications, though relatively rare, can include vocal cord paresis, chylothorax, pneumothorax, and recurrent nerve injury. In most cases, these complications are transient and resolve with conservative management. Studies emphasize the importance of meticulous dissection around the recurrent laryngeal nerve to avoid nerve damage. Another study noted that although complications like vocal cord paresis occurred in both thoracoscopic and open surgery groups, the overall complication rates were similar. The need for chest tube placement after thoracoscopic surgery has diminished in recent years. One report noted that while earlier cases required chest tubes, later cases often did not, contributing to shorter hospital stays and faster recovery times. Long-term follow-up data indicate that thoracoscopic division of vascular rings is highly effective in providing lasting symptom relief. One study reported that the vast majority of patients showed improvement in dysphagia and respiratory symptoms at a median follow-up of nearly eight years. The durability of symptom relief, even without resection of KommerellÕs diverticulum, was particularly notable. Thoracoscopic division of vascular rings has proven to be a safe and effective alternative to traditional open thoracotomy. It offers several advantages, including shorter hospital stays, faster recovery, and fewer postoperative complications. While both techniques demonstrate high rates of long-term symptom relief, thoracoscopy provides additional benefits in terms of cosmesis and postoperative pain management. As surgical techniques and instruments continue to evolve, thoracoscopic vascular ring division is likely to become the preferred approach for treating this congenital anomaly. References: 1- Al-Bassam A, Saquib Mallick M, Al-Qahtani A, Al-Tokhais T, Gado A, Al-Boukai A, Thalag A, Alsaadi M: Thoracoscopic division of vascular rings in infants and children. J Pediatr Surg. (8):1357-61, 2007 2- Slater BJ, Rothenberg SS: Thoracoscopic Management of Patent Ductus Arteriosus and Vascular Rings in Infants and Children. J Laparoendosc Adv Surg Tech A. 26(1):66-9, 2016 3- Lee JH, Yang JH, Jun TG: Video-assisted thoracoscopic division of vascular rings. Korean J Thorac Cardiovasc Surg. 48(1):78-81, 2015 4- Riggle KM, Rice-Townsend SE, Waldhausen JHT: Thoracoscopic division of vascular rings. J Pediatr Surg. 52(7):1113-1116, 2017 5- Herrin MA, Zurakowski D, Fynn-Thompson F, Baird CW, Del Nido PJ, Emani SM: Outcomes following thoracotomy or thoracoscopic vascular ring division in children and young adults. J Thorac Cardiovasc Surg. 154(2):607-615, 2017 6- Cockrell HC, Kwon EG, Savochka L, Dellinger MB, Greenberg SLM, Waldhausen JHT: Long-term Outcomes Following Thoracoscopic Division of Vascular Rings. J Pediatr Surg. 59(11):161542, 2024 |
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