Transcervical Zenker's Diverticulectomy
Considerations
Anatomy and eponyms
Cricopharyngeus muscle
Effectively the upper esophageal sphincter
Killian triangle (aka Killian-Jamieson triangle / area, Killian's dehiscence / hiatus)
The area of weakness directly superior to the cricopharyngeus and inferior to the thicker fibers of the thyropharyngeus portion of the inferior constrictor muscle
Generally accepted site of herniation of hypopharyngeal diverticula
Killian Jamieson area
A fat-filled lateral dehiscence that transmits the inferior laryngeal nerve and artery forward between the cricopharyngeus muscle above and the upper esophageal fibers below
Lamier area (aka Laimer / Lannier triangle, Laimer-Hackermann's area)
The area of weakness shaped like an inverted V (triangular) in the posterior esophageal wall between the divergent fibers of the outer longitudinal muscle just below the cricopharyngeus muscle
Zenker's diverticulum (aka pharyngo-esophageal / retropharyngeal / cricopharyngeal / hyopharyngeal puch / diverticulum)
The most common posterior pharyngeal pulsion diverticulum
Acquired
Located in Killian's triangle
Usually on the left
Usually 50+ years old
Usually Caucasians
Indications
Dysphagia +/- weight loss, aspiration +/- aspiration pneumonia
Compared to the endoscopic approach (see Endoscopic Cricopharyngeal Myotomy), generally...
Longer operating time with open
Better outcomes in terms of improved symptoms and less recurrence
Possibly higher complication rate
Longer hospital stay
May be preferable for very small or very large diverticulae
Preferable for recurrence (reoperation)
Note: Head to head, prospective studies are lacking
Cricopharyngeal myotomy (CP)
Complete CP myotomy should be performed during the open approach
2012: Principles of surgical treatment of Zenker diverticulum
Preparation
Equipment
Light source, cable, and light carrier
Esophageal (long velvet eye tip) suction
Jesberg esophagoscope
Weerda esophagoscope
Bougie
Methylene blue dye
Strip gauze, 1/4 inch, dyed
Head and neck major tray
Marking
Horizontal incision (~4-5 cm) just below the level of the cricoid extending from just left of the midline to just over the anterior sternocleidomastoid
Procedure
Esophagoscopy
ID the diverticulum, CP bar, normal esophagus
Suction the contents of the sac
Pack with sac with dyed strip gauze
Place a soft bougie in the esophagus
Incise the skin
Raise subplatysmal flaps
Incise the deep cervical fascia at the anterior border of the SCM
Identify and divide the omohyoid
Optional: Tag ends for later repair
Dissect medial to the carotid sheath to the prevertebral fascia
Identify the sac and dissect it free from the pharynx and esophagus
Key: Remove the attachments between the sac and the esophagus all the way up to the neck of the sac
Remove the strip gauze packing
Retract the sac
Excise the sac
Clamp and sharply divide
Repair the defect
3-0 Vicryl on CV-23 using classic Connell or imbricating technique
vs. enteral stapler
Perform full CP myotomy with myectomy
Key: Myotomy should be ~ 5 cm long and extend to the neck of the sac; Resect several mm of muscle on either side of the myotomy
Optional: Repair omohyoid
Remove the bougie
Optional: Place a DHT
Irrigate
Valsalva
Close over a passive drain
Fluff dressing
Sample operative report
Post-op
In PACU
Assess for crepitus
Order CXR to confirm proper DHT placement
Admit to MedSurg
Watch for mediastinitis - chest pain, fever, tachycardia +/- crepitus by palpation and/or auscultation (Hamman sign)
Nutrition consult for goal tube feeds
Medications per DHT once proper placement confirmed
Antibiotics x 24 hours peri-op
Unasyn vs Clindamycin (for Pen allergic)
Diet
NPO until POD 3
POD 3, start CLD and ADAT to mechanical soft
Penrose drain - Keep in place until until DHT removed POD 4
Follow up
RTC ***
Complications
Short term
RLN injury
Pharyngocutaneous fistula
Mediastinitis
Esophageal perforation
Long term
Failure of symptomatic improvement and recurrence of dysphagia