Correspondence Address:
S Ramesh
Indira Gandhi Institute of Child Health, Bengaluru, Karnataka
India

Full Text

The article is well written, quite relevant in the current context, and quite useful to the readers. This also reviews the current literature and adds personal experience, which has an impressive number.

The authors have described the approach and the various nuances quite well and I agree with their observations and experience except for a little variations here and thereThe upper pouch identification is better with a semi-rigid tube-like red rubber catheter or an endo-tracheal tube than with a feeding tube, which is pliableThe technique described for lung isolation with a Fogarty catheter is good, but may not be necessary. In most centers, we find it useful to have the lung being seen to be expanding to comfort the anesthetists. Single lung ventilation in a newborn child is less well tolerated by the anesthetists…! Further, such facility may not be available in many centersThe value of preoperative bronchoscopy is well highlighted. The position of the fistula can be assessed preoperatively and may help in identifying the area for dissection of the fistula. In two of our cases, it did really matter as in one, the fistula was quite high and it was quite low in the other. The initial dissection for the fistula could be accordingly done without much unnecessary dissection at a usual level at azygos veinFor the upper pouch dissection, we find that the magnification factor really helps. With steady traction on the esophagus, the plane between the trachea and esophagus can be seen well. We have also found that starting the dissection at a higher level is easier as the two structures are less adherent at that level. The dissection can then be brought to the lower levelThere are alternate techniques for anastomosis such as the sliding knot technique and the initially described "extracorporeal" suturing. Even though they cannot completely replace good intracorporeal suturing techniques in restricted spaces, they still have their place in cases of difficult anastomosisThe orientation and placement of sutures is very important, as the size discrepancy between the pouches can be disconcerting at timesEven though many surgeons prefer to leave the 3 mm port sites without closure, we prefer a fascial closure and a subcuticular stitch.