Total Laparoscopic Management of Large Epiphrenic Diverticulum

Introduction

Laparoscopic management of epiphrenic diverticula seems to be as safe and effective as the traditional, open transthoracic approach. However, in cases of large diverticula, the difficulty of dissection and the potential of the pleura to rupture with subsequent pneumothorax represent possible disadvantages. This video shows the safety of the laparoscopic approach for Heller myotomy and Dor fundoplication, combined with an epiphrenic diverticulectomy.

Materials and Methods

A 66-year-old woman presented to the authors’ institution complaining of dysphagia to solid foods, retrosternal pain, and weight loss. The preoperative examinations revealed a large diverticulum of the lower esophagus, approximately 4 cm above the lower esophageal sphincter (LES). Esophageal manometry showed lack of peristalsis and LES hypertension consistent with achalasia.

The patient was placed in the lithotomic position, with the operator standing between the patient’s legs. The first assistant was at the right of the surgeon, and the second assistant at his left. Pneumoperitoneum was established and five operating ports were placed as usual. The authors started with the dissection of the gastrohepatic ligament and continued until the right diaphragmatic pillar, with a complete dissection of the phrenoesophageal ligament. Afterwards, the lower esophagus was extensively mobilized in order to identify the diverticulum and the right mediastinal pleura was separated from the diverticulum laterally. When the diverticulum was completely free from its surrounding attachments, a 60 mm stapler was used to resect the diverticulum at its base, taking care to not narrow the esophagus.

After completion of the diverticulectomy, an anterior myotomy was performed, beginning at the upper level of the diverticular transection and ending 1.5-2 cm caudally into the gastric wall. The short gastric vessels of the fundus were divided along the fundus up to the left diaphragmatic crus using the harmonic scalpel. An anterior wrap (Dor fundoplication) was then performed by sewing the edges of the wrap to the edges of the myotomy with a suture. The wrap was then secured to the right crus of the diaphragm, superiorly.

Results and Conclusions

The operative time was 200 minutes. On postoperative day three, a barium swallow demonstrated that the esophagus was widely patent and had no leakage from either the diverticulectomy suture line or the myotomy. After a follow-up period of 14 months the patient is symptom free. In the authors’ opinion, this operation can be performed as a minimally invasive surgical procedure regardless of diverticula size. Technical factors also support this choice, including: better visualization of the esophagogastric junction, easier myotomy and performance of antireflux wrap, and better alignment of the stapler cartridge to the longitudinal axis of the esophagus. The only limiting factor is represented by the impossibility to extensively mobilize the lower esophagus.