Epiphrenic diverticula can be treated via a transabdominal or transthoracic approach and either as an open or minimally invasive procedure depending on the size and location of the diverticulum. If the diverticulum is located near the hiatus, a laparoscopic diverticulectomy with esophageal myotomy and partial fundoplication is readily accomplished, but it is important to recognize that many diverticula are more proximal than they appear radiographically, and only those very close to the gastroesophageal junction (GEJ) are amenable to a transabdominal or laparoscopic approach (Fig. 25-9). Most epiphrenic diverticula are located 5–10 cm proximal to the GEJ, and for these patients, a transthoracic approach is optimal. The approach is made via left thoracotomy in the seventh intercostal space. After incision of the mediastinal pleura and identification of the esophagus, the diverticulum can be dissected out and excised. Regardless of approach, once the diverticulum is identified, we prefer to excise it while a 52F bougie is in the esophagus to avoid narrowing the lumen. Subsequently, we close the muscle over the staple line with interrupted 3–0 silk sutures (Fig. 25-10) and perform the myotomy on the opposite side of the esophagus. Care is taken to avoid injuring the vagus nerves as the myotomy is carried down for 2–3 cm onto the anterior wall of the stomach along the greater curve side if possible (Fig. 25-11). Typically, a Dor partial fundoplication is performed (Fig. 25-12), but if there is a hiatal hernia, then crural closure with a Belsey or Toupet partial fundoplication is our standard procedure. Diverticula underneath the aortic arch are difficult to excise from the left chest and are better visualized from the right. In this setting, we prefer a two-stage approach. First, we perform a laparoscopic myotomy and partial fundoplication. In 6 weeks we bring the patient back to the OR for a thoracoscopic diverticulectomy and long esophageal myotomy from the right side.
The objectives of the procedure are identical regardless of the approach and include division of the dysfunctional esophageal muscle distal and adjacent to the diverticulum, excision of the diverticulum, and partial fundoplication to protect the esophagus from gastroesophageal reflux.1,8 A myotomy that ends at the GEJ is associated with a higher incidence of persistent or recurrent dysphagia than a myotomy that extends 2–3 cm onto the gastric side of the junction.1,8,9 In our opinion, the best location for the myotomy is along the left lateral aspect of the esophagus with continuation down across the angle of His at the greater curvature side of the stomach. Further, it is clear that the addition of a partial fundoplication reduces esophageal acid exposure after myotomy,10 and therefore, a partial fundoplication is added to the myotomy in all patients. If the etiology of the diverticulum is traction secondary to mediastinal adenopathy, a myotomy is not needed, and the treatment consists of separation of the esophagus from the culprit nodes (often difficult secondary to intense inflammation, fibrosis, and/or calcification) and excision of the diverticulum. This is best accomplished in most patients via the right chest either as an open or thoracoscopic procedure, and it may be helpful to place pleura or intercostal muscle between the esophageal repair and any residual mediastinal nodes to prevent leakage or recurrence.