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Esophageal diverticula are rare entities. They are commonly categorized by anatomic location and etiology. Epiphrenic diverticula occur in the distal third of the esophagus and develop by increased intraesophageal pressure secondary to a motility disorder. They are considered pulsion diverticula. Midesophageal diverticula have traditionally been considered traction diverticula and are associated with mediastinal inflammation. Recent work would suggest that most midesophageal diverticula are in fact pulsion diverticula and are associated with motility disorders. Patients with minimal symptoms or small diverticula should not be repaired because of postoperative anastomotic leak rates ranging from 6% to 18% and a perioperative morbidity rate of 33% to 45%. Diverticulectomy and myotomy can be recommended in patients who are symptomatic. The repair of large asymptomatic diverticula may warrant repair as well. Symptoms typically include dysphagia, regurgitation, or weight loss. Less often, chest pain, heartburn, aspiration pneumonia, or vomiting have been noted. It is sometimes difficult to determine the contribution of a diverticula versus a primary motility disorder as the cause of a patient’s symptoms.
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The traditional approach to an epiphrenic or midesophageal pulsion diverticulum would be a left thoracotomy, diverticulectomy, and myotomy. Depending on the extent of the myotomy, a Belsey Mark IV or other antireflux procedure would be considered. MIS diverticulectomy and myotomy should be tailored to the location of the diverticulum, its etiology, and the surgeon’s experience. Diverticula close to the esophageal hiatus can be approached with laparoscopy. A diverticulectomy, myotomy, and antireflux procedure can be performed through the laparoscope as described in Chapter 17. Care should be taken in the preoperative evaluation to ensure the diverticulum is within reach of the laparoscope. The esophageal hiatus is located at the 10th or 11th thoracic vertebra. The dome of the diaphragm can rise up to the level of the 4th thoracic vertebra, and a diverticulum, while appearing below the dome of the diaphragm, may be at the level of the carina and in the midesophagus. Thoracoscopy and diverticulectomy is indicated if laparoscopy fails to safely identify the diverticulum or finds the diverticulum too high in the chest to resect. In this situation, the lower extent of the myotomy and any required antireflux procedure would be performed through the laparoscope. The procedure would then be converted to right thoracoscopy for completion of the myotomy and resection of the diverticulum. Planned thoracoscopy and myotomy is indicated for midesophageal diverticula. The entire extent of the thoracic esophagus is most easily approached through the right chest. Procedures on the gastroesophageal junction, however, are very difficult from the right chest. If an antireflux procedure is needed, this should be performed through laparoscopy. Laparoscopy should be done first in order to prevent losing pneumoperitoneum through the thoracoscopy field. A long esophageal myotomy can be started 1 cm below the gastroesophageal junction thorough the laparoscope and completed later in the procedure through the thoracoscope. Left thoracoscopy, diverticulectomy, myotomy, and Belsey Mark IV fundoplication has been performed but was ...