Techniques my wayLaparoscopic Repair of Epiphrenic Diverticulum
Section snippets
Patient Selection
Surgery should be reserved for symptomatic patients, as the disease usually worsens with time, and may be responsible for potentially severe respiratory complications; asymptomatic diverticula are normally stable and do not require treatment. Regurgitation and dysphagia are the most common complaints but respiratory symptoms, especially caused by nocturnal aspiration, can also occur.
The diverticular neck must be localized within 10 cm above the esophagogastric junction. Barium swallow (Figure 1
Patient position
The patient is placed on the operating table in the lithotomy position with a 20° or 30° reverse Trendelenburg, with the surgeon standing between the legs. The first assistant, at the surgeon's right, holds the camera and a retracting grasper placed below the gastroesophageal junction. The second assistant may also stay on the surgeon's right, holding the liver retractor placed from the subxiphoidal port. Flexible endoscopic equipment is placed near the patient's head. A nasogastric tube is in
Additional Comments on Technique
A useful trick to increase visibility of the lower mediastinum and thus ease esophageal and diverticular exposure is the placement of 2 transparietal sutures, 1 in the left and 1 in the right hypocondrium, that grab both the crura. By applying traction to the sutures, the hiatus is held open.
Postoperative Care
The patient is usually maintained on parenteral fluids until postoperative day 3. At that time, the nasogastric tube is removed after a gastrographin swallow has demonstrated no leaks (Fig. 5).The patient is allowed clear fluids on postoperative day 3 and a semisolid diet thereafter. The drain is removed after the patient has had his liquid diet without problems.
If during this time the postoperative course is complicated (bile or salivary discharge from the drain, fever, leukocytosis,
Results
From January 1994 to July 2012, 30 patients with symptomatic epiphrenic diverticulum underwent laparoscopic repair (Table 1). There were 17 men and 13 women. Median age was 62 years (range: 37-89). Median distance of diverticular neck from cardia was 4 cm (range: 2-8), as measured preoperatively by endoscopy, and the median size of diverticular pouch was 3 cm (range: 1.2-9). The median length of myotomy was 9 cm (range: 5-13). Partial fundoplication consisted of 90° anterior procedures (Dor) in
Conclusions
Laparoscopic transhiatal surgery is in our opinion the preferred approach to treat epiphrenic diverticulum of the esophagus. The procedure has proven to be feasible and safe in experienced hands. It allows correction of the anatomic defect with a stapled diverticulectomy, treatment of the underlying motor disorder with an extramucosal myotomy (which should be performed in all patients, independently of the results of preoperative manometry, to prevent suture line leak and diverticular
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