Transcervical Cricopharyngeal Myotomy and Diverticulectomy or Suspension
The traditional approach for repair of a Zenker diverticulum is transcervical, with the patient positioned supine and the neck extended. An incision is made in the left neck along the anterior border of the sternocleidomastoid muscle. The sternocleidomastoid muscle and carotid sheath are retracted laterally. The omohyoid, sternothyroid, and sternohyoid muscles are divided to facilitate exposure of the cervical esophagus. The Zenker diverticulum will be located posterior to the cricoid cartilage. The diverticulum is sheathed in multiple layers of fibrous tissue that must be teased apart to permit exposure of the base of the diverticulum (Fig. 30-5).
Open repair of Zenker diverticulum. The Zenker diverticulum will be located posterior to the cricoid cartilage. The diverticulum is sheathed in multiple layers of fibrous tissue that must be teased apart to permit exposure of the base of the diverticulum.
Once exposed, a longitudinal myotomy on the posterolateral aspect of the cervical esophagus is started just inferior to the base of the diverticulum. It should extend inferiorly to the thoracic inlet, and then it is carried superiorly through the muscular ring of the cricopharyngeus at the base of the diverticulum. Typically, the muscle in the area of the base of the diverticulum is quite thick and fibrotic. Once released, the diverticulum should be clearly visualized. To ensure that all the dysfunctional fibers are divided, we also incise the lower fibers of the inferior pharyngeal constrictor superiorly from the base of the diverticulum for 1 to 2 cm. In addition, the edges of the divided muscle should be bluntly dissected to widely splay open the mucosa and permit identification and division of any residual circular muscle fibers.
Next, the diverticulum is either suspended or excised. Diverticula 2 cm or less in size are easily suspended by tacking the tip of the diverticulum with 3-0 Prolene to the precervical fascia as high up in the neck as necessary to fully upend the pouch. Larger pouches are difficult to fully upend and are best excised using a TA stapler with a 52F bougie in the esophagus to prevent narrowing of the esophageal lumen. The staple line and/or myotomy can be checked for leaks by passing a nasogastric tube into the area and insufflating air to distend the mucosa while the neck incision is filled with saline. This also provides an opportunity to ensure the mucosa distends fully with no residual bands in the area of the myotomy. Before neck closure, it is critical to ensure perfect hemostasis, because a hematoma requiring reexploration can develop from even small vessels secondary to coughing or straining as the patient awakens from anesthesia. We leave a small closed suction drain in place and approximate the platysma and skin to complete the operation.
Transoral Endoscopic-Stapled Diverticulotomy
A transoral endoscopic approach is another option for treating a Zenker diverticulum. This approach is attractive largely because it eliminates the neck incision, but limited because the pouch must be at least 3 cm in length and the patient must be able to extend the neck and open the mouth widely. Inability to extend the neck and open the mouth makes placement of the Storz rigid diverticuloscope difficult or impossible. If the diverticulum is less than 3 cm in length, it may not be possible to completely divide the dysfunctional cricopharyngeus muscle, leading to persistent or recurrent symptoms. Patients with evidence of malignancy inside the pouch are also not candidates for transoral stapling technique and instead require excision of the pouch.6 Although the procedure is quick and well tolerated, and in suitable patients produces excellent relief of dysphagia and regurgitation symptoms, patients must be warned of the possibility of chipped teeth secondary to the rigid scope insertion. In addition, most patients have considerable tongue swelling for a day or two after the procedure.
Before the procedure commences, a 30-mm GIA laparoscopic stapler is modified by cutting off the tip of the stapler with an orthopedic circular saw such that the knife blade and the staple line reach the end of the modified tip. The tip should be smoothed with a rasp or file. The patient is placed under general anesthesia and positioned supine with the neck extended, and the Storz diverticuloscope is inserted under direct visualization and advanced into the esophagus. It is helpful to have a pediatric flexible esophagoscope to facilitate placement of the rigid scope. The goal is to advance the longer anterior blade into the true lumen of the esophagus whereas the shorter posterior blade is advanced into the diverticulum. Once positioned, the blades of the scope are separated to permit clear visualization of the cricopharyngeus muscle band (Fig. 30-6). Using a laparoscopic needle holder, 3-0 Prolene traction sutures are placed on each side of the cricopharyngeus muscle (Fig. 30-7). With gentle traction on these stitches, the bar is held in position as the modified GIA stapler is inserted and fired (Fig. 30-8). Several applications of the stapler are typically necessary to divide the muscle bridge all the way to the tip of the diverticulum (Fig. 30-9). In this fashion, the cricopharyngeus muscle is divided, and the pouch is incorporated into the esophagus to create a single common cavity. If the diverticulum is less than 3 cm in length, the cricopharyngeus muscle will not be adequately divided, leading to a high rate of symptomatic failure and a significant risk for the development of a recurrent diverticulum. It is important to modify the stapler to minimize the amount of residual pouch with the transoral approach, since even a 1-cm remnant can lead to persistent symptoms. Although it is nearly impossible to completely eliminate the pouch, in our experience, patients with less than 4 to 5 mm of residual pouch remain asymptomatic.
Diverticuloscope positioned with the longer upper blade in the true lumen of the esophagus and the shorter blade in the diverticulum (lower left of picture). The cricopharyngeus muscle band is clearly seen between the blades.
Traction sutures in place in preparation for the stapling.
Complete transection of the cricopharyngeus achieved with multiple loads of a 30-mm GIA stapler. A common chamber now has been created between the true esophageal lumen and the diverticulum, and the dysfunctional cricopharyngeus muscle has been completely divided.
A. Modified 30-mm GIA stapler inserted and ready. B. Partial transection of the cricopharyngeus after use of a single 30-mm GIA stapler. Note the residual pouch.
Laparoscopic, Transabdominal, or Transthoracic Esophageal Myotomy; Diverticulectomy; and Partial Fundoplication (Triple Treat)
The objectives of the procedure for an epiphrenic diverticulum 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.1,7 A myotomy that ends at the gastroesophageal junction is associated with a higher incidence of persistent or recurrent dysphagia compared to a myotomy that extends 2 to 3 cm onto the gastric side of the junction.1,7,8 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 on the greater curvature side of the stomach. Further, it is clear that the addition of a partial fundoplication reduces esophageal acid exposure after myotomy,9 and therefore a partial fundoplication is added to the myotomy in all patients.
Epiphrenic diverticula can be treated via a transabdominal or transthoracic approach, and 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 are amenable to a transabdominal or laparoscopic approach (Fig. 30-10). Some epiphrenic diverticula are located 5 to 10 cm proximal to the gastroesophageal junction, and for these patients, a transthoracic approach is optimal. The approach is via left thoracotomy in the eighth intercostal space. After incision of the mediastinal pleura and identification of the esophagus, the diverticulum can be dissected. Once the diverticulum is dissected it can be excised using a TA stapler with a 52F or larger bougie in the esophagus to avoid narrowing the lumen. Subsequently, the muscle is reapproximated over the staple line with interrupted 3-0 silk sutures (Fig. 30-11), and a myotomy is performed on the opposite side of the esophagus and carried down for several centimeters on the greater curvature side of the stomach (Fig. 30-12). Typically, a Dor partial fundoplication is performed (Fig. 30-13), but if there is a hiatal hernia, then crural closure with a Belsey partial fundoplication is preferred. Diverticula underneath the aortic arch are difficult to excise from the left chest and are better visualized from the right. In this setting, a two-stage approach offers some advantages. The first stage is a laparoscopic myotomy and partial fundoplication, and then 6 weeks later the patient can be brought back for a thoracoscopic diverticulectomy and long esophageal myotomy through the right chest.
Epiphrenic diverticulum dissected by a laparoscopic approach.
Muscle approximated in interrupted fashion over the staple line after diverticulectomy over a 52F bougie. The myotomy is visible below the reapproximated muscle layers.
Laparoscopic myotomy along the anterolateral aspect of the esophagus exposing the mucosa across the gastroesophageal junction.
Completed Dor partial fundoplication.
Traction diverticula occur secondary to mediastinal adenopathy, and a myotomy is unnecessary. Treatment entails separating the esophagus from the culprit nodes (often difficult secondary to intense inflammation, fibrosis, and/or calcification) and excising the diverticulum. This is best accomplished in most patients via the right chest either as an open or thoracoscopic procedure. It is recommended that pleura or intercostal muscle is placed between the esophageal repair and any residual mediastinal nodes to prevent leakage or recurrence.