The indications for repairing a Zenker's diverticulum are partial obstruction, dysphagia, a choking sensation, pain on swallowing, or coughing spells associated with aspirations of fluid from the diverticulum. The diagnosis is confirmed by a barium swallow. The pouch appears suspended by a narrow neck from the esophagus. Zenker's diverticulum is a hernia of mucosa through a weak point located in the midline of the posterior wall of the esophagus where the inferior constrictors of the pharynx meet the cricopharyngeal muscle (Figure 1). The neck of the diverticulum arises just above the cricopharyngeal muscle, lies behind the esophagus, and usually projects left of midline. The barium collects and remains in the herniated mucosa of the esophagus.
The patient should be on a clear liquid diet for several days before operation. He or she should gargle with an antiseptic mouthwash. Antibiotic therapy may be initiated.
Endotracheal anesthesia is preferred through a cuffed endotracheal tube that is inflated to prevent any aspiration of material from the diverticulum. If general anesthesia is contraindicated, the operation can be performed under local or regional infiltration.
The patient is placed in a semierect position with a folded sheet under the shoulders. The head is angulated backward (Figure 2). The chin may be turned toward the right side if the surgeon wishes.
The patient's hair is covered with a snug gauze or mesh cap to avoid contamination of the field. The skin is prepared routinely, and the line of incision is marked along the anterior border of the sternocleidomastoid muscle, centered at the level of the thyroid cartilage (Figure 2). Skin towels may be eliminated by using a sterile adherent transparent plastic drape. A large sterile sheet with an oval opening completes the draping.