Laparoscopic diverticulectomy and esophageal myotomy for epiphrenic diverticulum

Diverticula of the distal esophagus, epiphrenic diverticula, are relatively rare. They have a tendency to enlarge and are frequently associated with neuromuscular dysfunction of the esophagus. In this video, we show the case of an 84-year-old lady referred to our surgical unit with symptoms of recurrent respiratory infection —including pneumonia—, severe regurgitation, food retention and chest pain.

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Laparoscopic diverticulectomy and esophageal myotomy for epiphrenic diverticulum

Authors

B Dallemagne, S Perretta, Gf Donatelli, J Marescaux

Abstract

Diverticula of the distal esophagus, epiphrenic diverticula, are relatively rare. They have a tendency to enlarge and are frequently associated with neuromuscular dysfunction of the esophagus. In this video, we show the case of an 84-year-old lady referred to our surgical unit with symptoms of recurrent respiratory infection —including pneumonia—, severe regurgitation, food retention and chest pain.

Keywords

Laparoscopy, diverticulectomy, esophageal myotomy, epiphrenic diverticulum, esophageal manometry, pulsion pseudodiverticula, distal esophagus, dysphagia

Media type

Surgical video

Duration

15'00''

Publication

2011-02

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E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3163.htm

Laparoscopic diverticulectomy and esophageal myotomy for epiphrenic diverticulum

1. Clinical case presentation 00'19''

Here we show the case of an 84-year-old lady referred to our surgical unit with symptoms of recurrent respiratory infection —including pneumonia—, severe regurgitation, food retention and chest pain. The subsequent diagnostic evaluation with endoscopy and barium swallow showed a large epiphrenic esophageal diverticulum.

2. Patient position 00'40''

The patient underwent general anesthesia and was placed in a reverse Trendelenburg position with the surgeon standing between the patient’s legs. Pneumoperitoneum was established using a Veress needle, and a constant intra-abdominal pressure of 12mmHg was maintained.

3. Intraoperative endoscopy 00'55''

The operation started with an intraoperative endoscopy to exactly locate the diverticulum in relationship to the gastroesophageal junction (GEJ). The endoscopy also assisted during the following steps of the operation, such as the stapling of the diverticular neck. A 5-trocar technique was used. First, a liver retractor was placed through the rightmost trocar to elevate the left liver lobe off the esophageal hiatus.

4. Dissection of gastroesophageal junction 01'28''

After division of the phrenoesophageal membrane, the dissection was continued circumferentially from the diaphragm to the left crus.

5. Esophageal dissection 01'53''

Afterwards, the esophagus was mobilized by careful dissection of the phrenogastric and phrenoesophageal attachments.

6. Introduction of umbilical tape and diverticulum dissection 02'44''

After creation of the retroesophageal window, an umbilical tape was used to retract the esophagus, which was then mobilized high up intrathoracically. The diverticulum was then also mobilized completely by careful preparation in the mediastinum using a combination of blunt dissection and Ligasure®. The vagus nerve was identified and preserved. Particularly dense adhesions were found between the pleura and the diverticulum. Care was taken not to incur in a large pleural opening during this step of the dissection. Epiphrenic diverticulum is an unusual disease which is normally associated with esophageal body motility disorders. The incidence is unknown. The corresponding symptomatology of epiphrenic esophageal diverticula ranges widely from primary symptoms like dysphagia and regurgitation to esophagitis, bleeding, and chest pain. The diagnosis of epiphrenic diverticulum is usually made on an upper gastrointestinal series. Oblique views can define the size, location, number and shape of diverticula. Contrast studies however are unreliable for evaluating motility patterns, and thus esophageal manometry should be performed preoperatively. Correct placement of the catheter can be difficult, such in our case, and may be assisted with endoscopic guidance. Esophageal manometry should be part of the work-up to evaluate lower esophageal sphincter pressure, lower esophageal sphincter relaxation and rule out achalasia, and esophageal body function in symptomatic patients. Esophageal endoscopy is recommended to exclude other etiologies for a dysphagia.

7. Diverticular sac transection 08'01''

Once the diverticulum has been completely isolated, the diverticular sac is transected using a single firing of an articulating Endo-GIA® stapler. A blue cartridge is used.

8. Staple line oversewing 08'59''

The esophageal staple line was then oversewn by a running suture. The division of the diverticular neck complete as well as the suture is performed under endoscopic control. The use of a bougie can then be avoided. The endoscope not only provides intraoperative visualization but also serves as a stent during stapling. This will avoid to provoke stenosis.

9. Myotomy 11'54''

A myotomy was then performed on the contralateral esophageal wall in order to prevent recurrence. The fat pad around the GEJ was carefully removed to achieve a perfect visualization of the esophageal muscular layer. The myotomy is initiated with cold scissors, and once the mucosal plane has been correctly identified, its reach can be extended proximally using the Ligasure®. The hook is used to take down any residual muscular bridge. The divided edges of the muscularis propria are gently mobilized laterally for half of the circumference of the esophagus. Electrocautery is rarely necessary and should be avoided in trying to attain hemostasis. Simple pressure is sufficient because of the risk of thermal injury to the exposed mucosa, and subsequent late perforation. The length of the esophageal myotomy is tailored to the underlying motility disorder. The cephalad extent of the myotomy should be through all regions of the esophagus documented to have an abnormal motility. If the motility is normal, the myotomy is carried out at the level above the diverticulum, which is typically between the inferior pulmonary vein and the aortic arch.

10. Crural defect closure 14'37''

The crural defect is then closed using a combination of posterior and anterior suture repair, paying attention to not overtighten the hiatus. Epiphrenic diverticula are pulsion pseudodiverticula of the distal esophagus usually located in a segment of 5-10cm above the GEJ on the right or left side —as in this case— of the esophagus. We believe that the transabdominal approach is easier and allows a better visualization of the hiatal area, especially when an extension of the operation such as a myotomy or fundoplication becomes necessary.

11. Specimen extraction 15'34''

The specimen is then retrieved in a plastic bag. Upper GI series revealed no leak, and the patient was allowed to liquid diet.