Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

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After the specimen is excised, the wound is irrigated. I use hydrogen peroxide because it helps localize any bleeding. Direct cautery through the foam of the peroxide can be carried out.

3. CLOSURE

The breast tissue is not closed. After hemostasis is secured, the incision is closed with running subcuticular absorbable sutures and a clear plastic dressing is applied.

STEP 4: POSTOPERATIVE CARE

I recommend that all patients who are going to have partial mastectomy for benign or malignant conditions wear a new sport or jogging bra after the procedure, because it gives good, nonrigid support to the breast.

An ice pack is often helpful to relieve localized pain, and one or two doses of nonopioid analgesic is usually all that is required. The dressing can be removed in the bath 24 to 36 hours after the operation, and no further dressing needs to be used.

STEP 5: PEARLS AND PITFALLS

The most important determination to be made is that pathologic nipple discharge is present and that resection will be required. Every patient must have a preoperative mammography, but there is no need for ductography or for cannulation of the ductal opening at the time of operation.

The duct can be identified with digital compression after the incision is made, or often the duct can be visualized and seen to be dilated, containing the dark fluid.

C H A P T E R 15

ZENKER’S DIVERTICULA

David B. Loran and Joseph B. Zwischenberger

STEP 1: SURGICAL ANATOMY

A comprehensive understanding of the anatomy of the esophagus is critical before undertaking surgical procedures on the esophagus.

Figure 15-1 demonstrates key anatomic structures that must be considered in surgical correction of Zenker’s diverticula.

STEP 2: PREOPERATIVE CONSIDERATIONS

Pharyngoesophageal (Zenker’s) diverticula, the most common diverticula of the esophagus, occur during the fifth to eighth decades of life. They are classified as pulsion diverticula and consist of mucosal and submucosal esophageal layers. Zenker’s diverticula are believed to result from either an uncoordinated relaxation or incomplete relaxation of the upper esophageal sphincter (cricopharyngeal muscle) during swallowing, resulting in higher than normal bolus pressures in the lower pharynx. This leads to herniation of the esophageal mucosa between the oblique fibers of the inferior constrictor muscle (superiorly) and the transverse fibers of the cricopharyngeal muscle (inferiorly) (see Figure 15-1). Small diverticula rarely produce symptoms. However, progressive enlargement of the diverticula leads to pronounced symptoms. Upper esophageal dysphagia, foul breath, and spontaneous regurgitation of undigested food material are characteristically seen. Rarely is a palpable mass encountered. Late manifestations include weight loss, hoarseness, and pulmonary abscess. Any symptomatic Zenker’s diverticulum should be corrected.

Barium esophagram is obtained to confirm the presence of a pharyngoesophageal diverticulum and localize it to the left or right side to assist in planning the surgical approach.

Anesthetic approach is dictated by the comorbidities of the patient and by surgeon preference. The procedure can be performed satisfactorily under a regional cervical block or a general anesthetic.

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The patient is placed supine on the operating room table, with the head slightly extended and turned away from the side of the incision. Some surgeons prefer to have the patient semirecumbent or seated.

Betadine preparation of the skin should be applied to cover the entire neck and upper chest. This should include the area from the mastoid process to the spinous processes posteriorly, along the angle of the mandible anteriorly, and to the level of the nipples inferiorly.

Various locations Weak areas for diverticula

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MC

A B

FIGURE 15–1

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STEP 3: OPERATIVE STEPS

1.INCISION

Almost all diverticula are best approached through the left side of the neck. Various

incisions can be used based on surgeon preference and patient anatomy. Most surgeons use an incision along the anterior border of the sternocleidomastoid muscle, from the level of the hyoid bone to 1 cm above the clavicle. Alternatively, a transverse cervical incision can be used within a prominent cervical fold centered over the middle third of the sternocleidomastoid muscle (Figure 15-2).

Skin incision

Diverticulum

FIGURE 15–2

2. DISSECTION

The incision is carried through the platysma to expose the deep cervical fascia. The sternocleidomastoid muscle and carotid sheath are retracted laterally to expose the retroesophageal space. Sometimes ligation of the middle thyroid vein is needed to adequately retract the thyroid gland and larynx medially. Care should be taken to avoid excessive retraction on the thyroid so that the recurrent laryngeal nerve, which courses superiorly in the tracheoesophageal groove, is not injured.

The omohyoid muscle, which can be divided, is retracted superiorly to complete exposure of the area and should bring into view the diverticulum as it emerges superior to the cricopharyngeal muscle (Figure 15-3).

Carotid artery

Sternocleidomastoid muscle

AOmohyoid muscle

Omohyoid muscle

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The diverticulum is grasped with an Allis or Babcock clamp and dissected free from the surrounding fibroadipose tissue to adequately expose the neck. A 36F to 40F bougie is placed into the pharynx by the anesthesiologist to help prevent narrowing of the esophagus with diverticulectomy and to facilitate dissection. A myotomy is performed with a no. 15 blade scalpel or Bovie electrocautery unit on low settings between a dissecting hemostat from the base of the diverticula through the entire length of the transverse cricopharyngeal muscle fibers and extended onto the longitudinal muscle fibers of the upper esophagus over a total length of 8 to 10 cm (Figure 15-4).

Diverticulum

Thyroid gland

FIGURE 15–4

The base of the diverticulum is now easily seen. Diverticula that measure less than 2 cm long usually do not require resection, and the mucosa will retract once the myotomy is performed. Those diverticula larger than 2 cm will require resection or “pex.” Many surgeons prefer to tack, or pex, the pouch cephalad on the pharynx (Figure 15-5).

Diverticulum

Incision

FIGURE 15–5

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A stapling device with 4.8-mm staples is oriented along the longitudinal esophageal axis with the bougie in place and is fired to resect the diverticulum (Figures 15-6 and 15-7).

Alternatively, the diverticula can be resected with a no. 15 blade scalpel and the mucosal defect closed with a running 4-0 absorbable suture.

Esophagus