Epiphrenic diverticula usually protrude from the right wall of the esophagus just above the gastroesophageal (GE) junction (Figure 1). They are usually associated with esophageal motility disorders, either diffuse esophageal spasm or achalasia. Even when preoperative esophageal motility does not detect a hypertensive nonrelaxing lower esophageal sphincter (LES), the treatment of choice for these lesions includes esophageal myotomy and diverticulectomy. Small, low-lying epiphrenic diverticula can be managed from the abdomen through the diaphragmatic hiatus. Large-mouth diverticula (greater than 3 cm) and those more than 3 cm above the hiatus should be approached through a right thoracoscopic approach as described in chapter 12. The chronically inflamed tissue often found adjacent to a diverticulum and the limited exposure of the mediastinum through an abdominal approach makes the transdiaphragmatic approach to large diverticula technically difficult and more hazardous than is necessary.
Symptoms of epiphrenic diverticula include frequent regurgitation, chest pain, regurgitation of partially digested food, and halitosis. These symptoms are often indistinguishable from the symptoms of achalasia, but because both conditions will be treated simultaneously, it is not necessary to make such distinctions.
Once the diagnosis of an epiphrenic diverticulum has been made with a barium swallow, the underlying motility disorder should be identified with esophageal manometry. Occasionally it is difficult to differentiate esophageal spasm from vigorous achalasia; however, with either condition, esophageal myotomy above the level of the diverticulum is indicated.
One of the more important steps in patient preparation (often overlooked) is preoperative endoscopy and diverticulum lavage. Epiphrenic diverticula are often chronically impacted with food debris. If the diverticula are not evacuated prior to operation, food debris will be caught in the staple line, leading to its disruption. Although it is possible to do this endoscopic irrigation and evacuation on the operative table after general anesthesia is induced, we prefer to do this preoperatively in the endoscopy lab to minimize the distention of the gut with gas that may occur from the performance of intraoperative esophagoscopy.
The patient is positioned supine with legs abducted as previously described for minimally invasive esophageal surgery (Figure 2).
The trocars are placed in a standard pattern as described for laparoscopic Nissen fundoplication (Figure 3). Likewise, initial dissection of the GE junction proceeds identically to that of the Nissen fundoplication as described in chapter 18.
A Penrose drain is placed around the GE junction, the first assistant ...