Surgery to repair OA/TOF is not an emergency, with the rare exception of the ventilated premature baby. It is safer, and better for everyone concerned, to keep a stable OA/TOF baby on a drip overnight and operate during daylight hours the following day.
Correction of OA/TOF involves division of the TOF and then repair of the OA.
This operation is performed in theatre under a general anaesthetic with an experienced paediatric anaesthetist continuously monitoring the baby’s vital signs; heart rate, ECG (the electrical activity in the heart), blood pressure, oxygen saturation (the oxygen-carrying capacity of the blood) and body temperature.
Most babies born with OA undergo a primary repair within the first few days of life. However, approximately 10% of babies have a gap between the upper and lower ends of the oesophagus which is too long for a primary repair. In these cases the surgery will be delayed.
See: Long gap OA – delayed primary anastomosis for more information.
Repair of the oesophageal atresia is usually performed through an opening in the right chest wall called a thoracotomy. The baby is positioned on their side with their arm above the head. The skin is cleaned with antiseptic and an incision made just below the tip of the shoulder blade, following the curve of the ribs around the side of the chest.
The chest cavity is usually entered between the fourth and fifth ribs. The surgeon aims to keep the right lung within its covering membrane (the pleura), carefully sweeping it away from the chest wall.
The first part of the repair involves finding and disconnecting the TOF. Once the fistula is divided, the opening into the trachea is repaired with stitches (sutures).
If the baby is unstable the operation can be stopped safely at this stage and the chest closed to minimise operating time. The thoracotomy can be reopened and the two ends of the oesophagus joined up (anastomosed) another day, when the baby is more stable.
The next step is to identify the upper pouch of the oesophagus. The upper pouch is freed from attachments to the surrounding tissues. The surgeon must assess the gap between the upper and lower ends of the oesophagus to determine if it is possible to join the ends together and repair the atresia by anastomosis. The length of the gap varies.
In most cases, a primary anastomosis (or primary repair of OA) is possible i.e. the two ends can be joined up immediately.
The aim is to repair the oesophagus with as little tension as possible on the ends.
Once most of the sutures are in place, the anaesthetist will usually pass a small feeding tube down the baby’s nose and into the upper oesophagus. The surgeon then guides this tube across the anastomosis into the stomach. This transanastomotic tube or TAT tube allows milk to be fed directly into the stomach during the first few days after the operation, until the baby is well enough to feed by mouth.
After completion of the repair, the chest is closed in layers, with all sutures placed underneath the skin so that no stitches require removal at a later date. Some surgeons leave a chest drain in place for a few days, especially if the repair of the oesophagus was made under tension and there is a concern that the join might leak. In many cases a drain is not required.