Thoracoscopic Repair of a Vascular Ring Formed by a Right Aortic Arch and a Left Ligamentum Arteriosum

Introduction
Vascular ring is a congenital anomaly of the aortic arch that compresses the esophagus and/or trachea. It can be asymptomatic for life and not require any intervention. On the contrary, there are some vascular rings that are associated with respiratory (frequent infections, stridor, cough, distress) and esophageal (difficulty feeding, gastroesophageal reflux, dysphagia) symptoms. The most common vascular rings are double aortic arch and right aortic arch with left ligamentum arteriosum.

Case Report
The patient was a 4-year-old, 20 kilogram girl with recurrent pneumonia and bronchospasm without esophageal symptoms. The CT scan revealed a type I Edwards right aortic arch with a mirror image and left ligamentum arteriosum that caused a distal trachea and right bronchus compression.

Operation Technique and Result
The patient was placed in the right lateral decubitus position. Two 3 millimetres and two 5 millimetres trocars were inserted. A 5 millimetre 30-degree angle camera was advanced and C02 was insufflated until lung collapse was achieved. It is also helpful to use a left bronchus blocker.

The mediastinal pleura was opened from the left subclavian artery to the descending aorta. The crossing vein was dissected and divided with Ligasure Maryland (Medtronic Ligasure Tm Maryland Jaw Thoracic Sealer-Divider). The ligamentum arteriosum was dissected and controlled with a vessel loop with special caution of the left recurrent laryngeal nerve. The ligamentum was ligated with four hem-o-lok clips (Teleflex Medical Weck Closure System). It was cut leaving two clips on each side. Adhesive bands surrounding the esophagus and trachea were dissected and divided. Tisseel (Baxter Healthcare Corp) was used for prevention of lymphatic leakage. The mediastinal pleura was left widely open. Closure was performed with absorbable sutures without pleural drainage.

The postoperative bronchoscopy in the OR showed clear improvement of the compression. The patient was extubated in the OR. Intensive care unit stay was one day. The postoperative course was uneventful. The patient was discharged home five days after surgery.

References

1. 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. 2017;154(2):607-615.
2. Riggle KM, Rice-Townsend SE, Waldhausen JHT. Thoracoscopic division of vascular rings. J Pediatr Surg. 2017;52(7):1113-1116.
3. Koontz CS, Bhatia A, Forbess J, Wulkan ML. Video-assisted thoracoscopic division of vascular rings in pediatric patients. Am Surg. 2005;71(4):289-291.

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