Epiphrenic esophageal diverticulum: a two-step laparoscopic treatment

This video demonstrates a patient with epiphrenic esophageal diverticulum. The patient first undergoes a laparoscopic Heller's myotomy but does not experience significant improvement in his symptoms. Subsequently the patient undergoes a diverticulectomy through a right thoracoscopic approach.

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Epiphrenic esophageal diverticulum: a two-step laparoscopic treatment

Authors

S Sereno, B Dallemagne, J Marescaux

Abstract

This video demonstrates a patient with epiphrenic esophageal diverticulum. The patient first undergoes a laparoscopic Heller's myotomy but does not experience significant improvement in his symptoms. Subsequently the patient undergoes a diverticulectomy through a right thoracoscopic approach.

Classification

complex cases

Keywords

esophageal diverticulum, thoracoscopy, Heller\'s myotomy, laparoscopy

Media type

Surgical video

Duration

07'00''

Publication

2006-11

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E-publication

WeBSurg.com, Nov 2006;6(11).
URL: http://www.websurg.com/doi-vd01en2009.htm

Epiphrenic esophageal diverticulum: a two-step laparoscopic treatment

1. Case presentation 00'17''

We present a two-step surgical treatment of an 84-year-old woman with an epiphrenic esophageal diverticulum. She presented through the emergency room with a history of recurrent dysphagia, chest pain, vomiting and one episode of hematemesis. CT-scan, EGD and upper GI showed a dilated esophagus and a diverticulum of the lower esophagus, a narrowed esophagogastric junction suggested achalasia. We decided to perform a laparoscopic Heller myotomy.

2. First operation 00'50''

We started by dissecting the gastro-esophageal junction and carried out the dissection into the mediastinum up to the level of the diverticulum. We wanted to relieve the outlet obstruction syndrome hoping to improve the patient’s symptoms with one minimally invasive procedure. The esophageal part of the myotomy is done with scissors over a length of about 8 cm reaching up to the area of the diverticulum. Careful dissection allows a good protrusion of the esophageal mucosa confirming a good myotomy. The myotomy is then extended into the first two centimetres of the gastric part of the junction with monopolar hook. All muscular fibres are divided to ensure completeness of the myotomy to avoid recurrence of outlet symptoms. The resulting Heller myotomy is very satisfying. The upper GI shows complete resolution of the outlet obstruction. The patient improved with partial remission of the symptoms.

3. Second operation 02'37''

Although the upper GI showed no outlet problem at the GE junction, 4 months later the patient was still complaining of dysphagia and regurgitation, so resection of the diverticulum was the next therapeutic step to be taken. We performed the resection of the diverticulum by thoracoscopy. The patient is lying on left lateral decubitus. The right lung is collapsed with selective intubation. Three trocars are carefully placed taking in consideration the scoliotic anatomy of the patient. The goal is to have a good triangulation with two working ports and a camera. Progressive dissection of the mediastinum leads us to identify the inferior vena cava. Further dissection into the mediastinum allows the exposure of the inferior third of the esophagus and the diverticulum. Adhesions are progressively sectioned. The right pleura is opened over the mediastinum and dissected away. The diverticulum is exposed and completely dissected. Dissection of the diverticulum continues with good exposure of the muscular fibres of the esophagus. The diverticulum has a large base of about 5 cm; it is adherent to the posterior aspect of the esophagus. The scoliotic anatomy of the patient makes surgery a bit more difficult. At the end of the dissection, a 50 French bougie is introduced in the esophagus for calibration during the resection. The diverticulum is resected at its base with two firings of an endo-GIA stapler with a vascular cartridge. We used a running suture of 4/0 polysorb to cover the diverticular stump.

4. End of procedure and post-operative 06'37''

The specimen was withdrawn in a plastic bag. The area is carefully cleaned with suction and irrigation. The patient is doing well with no symptoms of dysphagia. The control upper GI shows very good results.