Use of the exoscope (VITOM) for open transthoracic repair of recurrent tracheoesophageal fistula in a child: Enhanced visualization and documentation of uncommon cases in pediatric surgery

Philip K Frykman, MD, PhD, MBA, Scott S Short, MD, George Berci, MD. Division of Pediatric Surgery, Department of Surgery, Cedars-Sinai Medical Center.

Objectives:  To highlight the use of exoscopy using the video telescopic operative microscope VITOM®  (Karl Storz Endoscopy) in management of a child with a recurrent tracheoesophageal fistula (TEF).  The VITOM is an emerging technology aimed at providing enhanced visualization of open procedures requiring magnification to all members of the operating team and for documenting uncommon cases.


Description: A 5 year-old boy, two years status post endoscopic repair with combined fistula de-epithelialization and fibrin glue presented with a recurrent TEF at the level of the carina.  We chose a multimodal strategy combining endoscopic localization of the fistula with the VITOM® high-definition exoscope for magnification and enhanced visualization of critical structures.  We used a right 5th ICS  approach through a previous thoracotomy to achieve exposure of the fistula.  The boundaries of the fistula were clearly identified and the fistula was divided.  Both trachea and esophagus were closed with interrupted sutures and a pleural flap was placed between the suture lines.  The patient had a successful recovery with no leak or residual TEF.


Preliminary Data: The VITOM provided high-definition magnified images of the transthoracic operation displayed on a flat screen viewable by all team members, including scrub tech and circulating nurse who otherwise cannot visualize operation progression through the thoractomy.  The scrub tech found the VITOM images aided her ability to anticipate next steps in the operation thereby enhancing operation flow; the medical student felt magnified images enhanced learning.  The video documentation of this case has been edited to create a short educational video detailing the steps of the operation for review by resident and attending staff prior to similar operations in the future.


Conclusions: VITOM provides excellent visualization of open pediatric operations to all team members and may enhance operation flow and learning by trainees.  VITOM is ideal for capturing uncommonly performed pediatric operations for use as future training videos.  Further study of VITOM with larger sample size and validated tools is needed.

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