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INDICATIONS

The indications for repairing 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. Swallowed barium collects and remains in the herniated mucosa of the esophagus. The procedure described herein is an open technique and should be applied when a transoral stapling technique is not feasible. The open approach has the advantage of complete removal of the pouch with a low chance of recurrence. Furthermore, it provides a histologic specimen to exclude carcinoma within the pouch. Small pouches (<1 cm) can be treated with cricopharyngeal myotomy alone, which may not be feasible endoscopically. Disadvantages of the open procedure consist of a longer hospital stay and significant complications including recurrent laryngeal nerve injury and pharyngeal leak with mediastinitis.

PREOPERATIVE PREPARATION

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.

ANESTHESIA

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.

POSITION

Patients are placed in a semierect position with a shoulder roll under the shoulders. The head is angulated backward (FIGURE 2). The chin may be turned toward the right side if the surgeon wishes.

OPERATIVE PREPARATION

The patient’s hair is covered with a snug 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. Then a time-out is performed.

INCISION AND EXPOSURE

The surgeon stands on the patient’s left side. He or she should be thoroughly familiar with the anatomy of the neck and aware that a sensory branch of the cervical plexus, the cervical cutaneous nerve, crosses the incision 2–3 cm below the angle of the jaw (FIGURE 3). The surgeon applies firm pressure over ...

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