Techniques my way
Laparoscopic Repair of Epiphrenic Diverticulum

https://doi.org/10.1053/j.semtcvs.2012.10.003Get rights and content

Epiphrenic diverticulum of the esophagus is an uncommon disease, and its pathogenesis remains unclear. Surgical repair of this disease is warranted only for symptomatic patients because treatment carries high risk of morbidity. Over the past decade, the laparoscopic approach to epiphrenic diverticulectomy has been shown to be safe and effective. The aim of the study was to describe our specific approach to the procedure and results. From 1994 to 2012, 30 patients with symptomatic epiphrenic diverticulum underwent laparoscopic surgery. There were no conversions to open surgery. The postoperative course was uneventful in 28 patients (93.3%). One patient had a suture line leak, which required repair through right thoracotomy, and 1 patient had a hemoperitoneum, which needed an open splenectomy. The median follow-up was 52 months (2-144). To date, no patient has presented with a recurrence. Laparoscopic transhiatal surgery is in our opinion the preferred approach to treatment of epiphrenic diverticulum of the esophagus. The procedure has proven to be feasible and safe in experienced hands. Long-term results, both clinical and with an objective evaluation, are satisfactory.

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

References (6)

There are more references available in the full text version of this article.

Cited by (0)

View full text