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432 Atlas of Gastrointestinal Surgery: Esophagus
Most patients will do well in the long term
with just a diverticulectomy. Recurrences
do occur, however; to prevent these,
an esophagomyotomy should be
performed (6). The myotomy is
performed along the lateral
esophageal wall, to avoid the
area previously closed at the
site of the diverticulectomy (7,
8). The muscle layer of the
esophagus is easily separated from
the underlying mucosa with a fine
right angle clamp and divided with the
electrocautery on low voltage. The myotomy should extend approximately 3 to 4 cm,
being certain that it is brought cephalad to the
point where the cricopharyngeus muscle is completely
divided. A small Penrose or closed-suction drain is left around
the area of the diverticulectomy and is brought out inferior to the
operative site. The wound is closed in layers.
Esophagus
Esophageal mucosa
Lateral
esophagomyotomy
Cricopharyngeal m.
6
Posterior
Lateral
esophagomyotomy
Recurrent laryngeal n.
Trachea
Thyroid
7
Anterior
8
Suspension of Zenker’s Diverticulum
Operative Indications
For patients who present with symptoms of a Zenker’s diverticulum and in whom the Zenker’s diverticulum is small (< 3
cm), one has the option of not resecting the diverticulum but merely suspending it. This may also be a useful approach in
the high-risk surgical patient, and thus could be done under sedation with local anesthesia. An esophagomyotomy is added
below the diverticulum. In several small series, this has proven to be entirely satisfactory. If one tries to suspend a large
diverticulum, however, symptoms may persist or recur, and reoperation becomes necessary. Therefore, the operation of suspension of the diverticulum should be performed only for small diverticula. The advantage of this operative procedure over
diverticulectomy is that the esophagus is not opened. This is only a small advantage because leakage at the site of the diverticulectomy is uncommon. Nevertheless, some esophageal surgeons favor this operative procedure.
Operative Technique
The patient is placed in the supine position, with the head rotated to the right. An
incision is made along the anterior border of the left sternocleidomastoid muscle. The
initial part of the operative procedure is identical to that for diverticulectomy.
434 Atlas of Gastrointestinal Surgery: Esophagus
The omohyoid muscle is divided, the middle thyroid vein is divided, and the carotid sheath is retracted laterally along with
the sternocleidomastoid muscle. The trachea and thyroid are gently retracted medially. The diverticulum is identified and
dissected free. An esophagomyotomy is performed beginning at the defect in the muscular layer at the neck of the diverticulum, and extended inferiorly for approximately 4 cm, thus ensuring that
the entire cricopharyngeus muscle is divided. The esophagomyotomy is
performed by dissecting the muscle layer from the mucosa with a right
angle clamp and dividing it with the electrocautery (1). When the
myotomy is completed, the diverticulum is gently stretched in a
cephalad direction and fixed to the prevertebral fascia with two
or three 3-0 silk sutures (2, 3). Since the esophagus has not
been entered, the wound is not drained.
2
Diverticulum
fixed to
prevertebral
fascia
Esophagus
Cricopharyngeus m.
divided
1
Diverticulum
Esophagus
Sternocleidomastoid m.
3
Esophagus
Suspended
diverticulum
Resection of Epiphrenic Esophageal
Diverticulum with Esophagomyotomy
and Belsey Repair
Operative Indications
Esophageal mucosa
Epiphrenic diverticula are pulsion pseudodiverticula that
are secondary to discoordination of the lower
esophageal high-pressure zone. The underlying
pathophysiology of this motor disorder is not entirely clear. Epiphrenic diverticula invariably arise above
the lower esophageal sphincter, and generally present to the right (1). They can become quite large
over time if left untreated. Patients generally present
with mild dysphagia, with occasional regurgitation
of previously ingested food. Recurrent bouts of
aspiration can occur but are less frequently seen
than with a Zenker’s diverticulum. Symptoms
of dysphagia may be relatively mild; if a
patient is elderly and frail, surgical intervention
may not be mandatory. However, for most
Esophagus
Left (anterior) vagus n.
Stomach
patients who present with symptomatic
epiphrenic diverticula, surgical management is indicated. There is no medical management for this disorder.
1
436 Atlas of Gastrointestinal Surgery: Esophagus
Operative Technique
The patient is placed in the lateral thoracotomy position with the left chest up.
The left pleural cavity is entered through the sixth or seventh intercostal space.
The mediastinal pleura is opened and the esophagus is identified. Identification of
the esophagus is aided by having a nasogastric tube in place. The nasogastric tube,
however, will generally enter the diverticulum and therefore has to be inserted with
care to avoid perforation. The esophagus is identified and mobilized. It is looped
with a small Penrose drain for gentle traction (2). As the esophagus is mobilized,
the pulsion diverticulum will be identified arising from the right lateral aspect of
the distal esophagus, residing in the mediastinum to the right of the midline.
Despite the fact that these generally present to the right, they are easily accessed
from a left posterolateral thoracotomy. The diverticulum is mobilized with both
blunt and sharp dissection, aided by grasping it with a small Babcock clamp.
These are generally imbedded in soft areolar tissue and easily dissected free.
When the diverticulum has been completely mobilized, the esophagus is rotated to expose the muscular defect. The nasogastric tube is then advanced
into the stomach. The diverticulum is excised
using a thoracoabdominal (TA) stapler
(3). As previously described for
Zenker’s diverticulum, one has to
be certain that mucosa from the
esophagus is not tented out and
Diverticulum
mobilized
Mediastinial
pleura
opened
removed, thus narrowing the
esophageal lumen. A 46 French
Maloney dilator is inserted to
avoid this problem. The diverticulum should be opened at the apex
if residual food debris is palpated so
it is not incorporated in the staple line.
The muscular layer is closed over the staple line with a series of interrupted 3-0 silk
sutures (4, inset).
Esophagus
looped with
Penrose
drain
2
Resection of Epiphrenic Esophageal Diverticulum with Esophagomyotomy and Belsey Repair 437
Diverticulum
resected
Stapled mucosa
Esophagus
3
TA
stapler
rotated
laterally
Muscular layer of
esophagus closed
over staple line
4
With the diverticulum completely excised, attention is turned toward the esophageal motility disorder commonly associated with these diverticula. This is managed with a distal esophagomyotomy. Once the esophagomyotomy is performed
and the lower esophageal sphincter destroyed, a new sphincter needs to be created by performing a loose Belsey Mark
IV antireflux repair. To accomplish this, the distal esophagus and hiatus are further mobilized, bringing the fundus of the
stomach up into the chest. This mobilization includes divi-
Fundus brought
into chest
Fat pad
sion of branches of the left gastric vessels along the
lesser curvature of the stomach and the upper vasa
brevia along the greater curvature, with removal
5
of the fat pad along the esophagogastric junc-
tion anteriorly (5).
438 Atlas of Gastrointestinal Surgery: Esophagus
Once the distal esophagus and fundus of the stomach have been
mobilized sufficiently, an esophagomyotomy is performed that
involves the distal 5 cm of the esophagus and extends onto the
gastric wall for at least 1 cm. The muscle layer of the esoph-
Fundus
6
agus is elevated from the mucosa with a right angle clamp
and is divided with either scissors or the electrocautery (6).
7
Esophageal mucosa
Muscular layer of
esophagus dissected
Esophagomyotomy
The muscle layer is then dissected free from the esophageal
mucosa for at least 50% of the circumference of the
esophagus (7). This dissection is easily accomplished
with scissors using both sharp and blunt dissection.
The fundus of the stomach is further mobilized in
preparation for performing a Belsey Mark IV antireflux
procedure. Because the esophageal hiatus has been
stretched to dissect the fundus and deliver it into
the chest, interrupted crural sutures of No. 2 silk
are placed posteriorly. A modified Belsey procedure is then performed (8).
Instead of the usual two rows of three sutures,
two rows of only two sutures are placed. One horizontal mattress suture is placed on either side of the
myotomy in each row. For the first row, a suture of 20 silk is placed through gastric fundus 2 cm from the gas-
First row placed
8
Crural
sutures
Resection of Epiphrenic Esophageal Diverticulum with Esophagomyotomy and Belsey Repair 439
troesophageal junction, then longitudinally through the esophagus lateral to the esophagomyotomy, 2 cm above the gastroesophageal junction. The mattress suture is brought back down
through the esophagus and stomach. A similar suture is placed
on the other side of the esophagomyotomy (8).
First row tied
9
Second row placed
through diaphragm
10
After tying both sutures (9), a second row of two
sutures is then placed by first passing the 2-0 silk
through the diaphragm (from the chest to the abdom-
inal side), through fundus of the stomach 2 cm below
the first row of repair sutures, and then longitudinally
through the esophagus 2 cm above the first row. The
mattress suture is brought back down through the
esophagus and fundus and out through the diaphragm.
Two such sutures are placed, one on either side of the
myotomy. The placement of the diaphragmatic portions of
the sutures is aided by retraction with a large spoon (10).
Once both sutures of the second row have been placed, the fun-
dus of the stomach is reduced below the diaphragm, and the two
sutures are secured. The previously placed diaphragmatic crural
sutures are secured (11). When securing these crural sutures,
one should have in place an indwelling 46 French Maloney dilator and a nasogastric tube, leaving only enough space between
the esophagus and the crural sutures to admit a fingertip.
Second row tied
Crural
sutures tied
11
440 Atlas of Gastrointestinal Surgery: Esophagus
Thus, the procedure has resulted in resection of the diverticulum,
destruction of the discoordinated lower esophageal sphincter, and construction of a new sphincter with a Belsey Mark IV procedure (12, 13, 14).
The integrity of the esophageal mucosa can be checked by exchanging the
Diverticulum
repair
Esophagomyotoomy
Maloney dilator with a flexible esophagoscope, submerging the
area under saline, and insufflating the esophagus while holding
distal pressure on the lumen. Any leaks should be repaired
with a 4-0 absorbable suture. A chest tube is inserted, and
the thoracotomy incision closed.
Vagus nerves
posterior
to esophagus
270˚ wrap of
stomach
Second and first
rows of Belsey
repair
12
13 14
Achalasia: Heller Esophagomyotomy
and Belsey Repair
Operative Indications
Achalasia is an esophageal disorder that presents as dysphagia and is secondary to
failure of relaxation of the lower esophageal sphincter and the absence of progressive
peristalsis in the esophagus. Failure of the sphincter to relax with swallowing, along
with a higher resting pressure, are characteristics of this disorder. It presents insidiously over a long period. Since the symptoms of dysphagia are gradual and may not
be appreciated initially, when achalasia is finally diagnosed, a very large dilated
esophagus may be present (1). In many institutions, the initial management of achalasia is with either balloon dilatation, or by local injection of the lower esophageal
sphincter with botulinum toxin. Each of these may require two or more treatments. In
at least half of the patients, these treatments are eventually ineffective. For patients
who fail these two options, or who subsequently have a recurrence, surgically destroying the lower esophageal sphincter by Heller
esophagomyotomy and then creating a new sphincter with a Belsey
Mark IV operation is the procedure of choice.
Hypertrophied,
dilated esophagus
1