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92
A. Shu and V. Sharp
• Divide the mesoappendix and then the base of the appendix; remove appendix from the abdomen
• Suction the right lower quadrant and pelvis, ensure
hemostasis
• Remove ports under direct visualization and close port
sites
Open Appendectomy
• General anesthesia, supine position
• Transverse skin incision at McBurney’s point
• Dissect down to the external oblique aponeurosis
• Open the aponeurosis parallel to its bers and expose the
internal oblique muscle
• Bluntly separate the muscle bers to expose the
peritoneum
• Elevate and incise the peritoneum
• Identify the appendix by locating the cecum and following the taenia to where they converge
• Ligate and divide the mesoappendix and then the
appendix
• Cauterize the mucosa of the appendiceal stump and then
invaginate it into the cecum with suture
• Irrigate and then close the incision in layers with consideration for delayed primary or secondary closure
Common Curveballs
• Damage to cecum, terminal ileum, or iliac vessels
• Carcinoid or adenocarcinoma on pathology
• Appendicitis in pregnancy
• Intraoperative ndings of Crohn’s disease or a Meckel’s
diverticulum
• Postoperative ileus or abscess
• Postoperative wound infection is staple line leak/stula
Clean Kills
• Inadequate abdominal exploration due to limited incision
• Division of inamed base of the appendix
• Failure to resect normal appendix during open appendectomy
Bibliography
Cameron J, Cameron A, Kovler ML, Hackam DJ. Appendicitis. In:
Current surgical therapy. 13th ed. Elsevier; 2020.
Zollinger RM, Bitans M, Cutler EC.Zollinger’s atlas of surgical opera-
tions. McGraw Hill, Medical Publishing Division; 2003.
Crohn’s Disease
ArielleBrackett, JosephA.Sciacca, andDavidPalange
31
Concept
Crohn’s disease (CD) is a chronic inammatory bowel disease of uncertain etiology. Inammation is transmural,
involving the full thickness of the bowel wall, and can affect
any portion of the gastrointestinal tract, though most common anatomic patterns include ileocolic disease, small intestinal disease, isolated colonic disease, and gastroduodenal
disease. CD has a bimodal age distribution with the rst peak
occurring between ages 15–30 and the second between 60
and 80s. Disease behavior is classied into three categories:
inammatory, stricturing, and stulizing. Pathology includes
skip lesions, aphthous ulcers, patchy erythema, deep “bear
claw” ulceration, and non-caseating granulomas.
CD is not curable. Initial management is medical therapy,
as few patients will require surgery at initial disease presentation. Medical treatment involves an induction phase followed by maintenance of remission. Operative intervention
is intended to address complications and alleviate symptoms
and is indicated for medically refractory disease, symptomatic stulas, neoplasia, or emergent situations including massive hemorrhage, free perforation, or acute obstruction.
Way Questions May BeAsked?
“A 60-year-old male with a history of Crohn’s disease
who has been admitted for an acute Crohn’s are develops
new abdominal distention and worsened abdominal pain.”
Patient may also be exhibiting fever, tachycardia, hypotension, and other signs of sepsis or shock.
How toAnswer?
History
• Previous episodes of abdominal pain, diarrhea
• History of weight loss or difculty with weight gain
• Family history of inammatory bowel disease/cancer
history
• Extraintestinal manifestations (present in 30%): erythema
multiforme, erythema nodosum, pyoderma gangrenosum,
iritis, uveitis, conjunctivitis, arthritis, ankylosing spondy-
litis, sclerosing cholangitis
Physical Examination
• Vital signs
• Abdominal exam (tenderness vs. peritoneal signs)
• Body habitus (cachexia)
• Remember to evaluate both the oropharynx (for ulcers)
and rectum/perineum (for stulas)
“A 25-year-old male presents with intermittent abdominal
pain which has been progressively worsening with associated diarrhea. He has a thin appearance and states he has had
trouble gaining weight since puberty.”
“A 19-year-old female with a history of abdominal pain
and diarrhea who now presents with postprandial nausea and
bloating without emesis.”
A. Brackett · J. A. Sciacca · D. Palange (*)
Division of Surgery, Christiana Care Health System,
Newark, DE, USA
e-mail: arielle.brackett@christianacare.org;
joseph.sciacca@christianacare.org;
david.palange@christianacare.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_31
Diagnostic Tests
• Full laboratory panel focusing on white blood cell count
(if concern for complication like intraabdominal abscess
or perforation) and total protein, albumin, prealbumin,
fecal calprotectin
• Key to evaluation of CD is determining extent and location of involved intestines; this can be accomplished with
contrast studies, CT, and MRI imaging
• Contrast study may show cobblestoning, strictures, or
stulas
• CT scans are also useful in evaluating for acute complications such as abscess, obstruction, perforation, stulas, or
abscesses
93
94
A. Brackett et al.
• Endoscopy is critical in workup and surveillance of CD,
and both colonoscopy and esophagogastroduodenoscopy
should be performed to evaluate for mucosal inammation and obtain tissue for diagnosis
• However, there is high risk of perforation from colonoscopy when performed during period of acute inammation
so colonoscopy is generally avoided in an acute setting
• Stool Studies for C. difcile, ova and parasites, enteric
pathogens
Treatment
The initial management of CD is medical therapy. Medical
treatment involves an induction phase followed by maintenance of remission. Intravenous steroids can be used as rstline induction to treat acute inammation, as well as oral
glucocorticoids or 5-aminosalicylates (5-ASA) in patients
for whom steroids are contraindicated. 5-ASA agents may be
continued for long-term maintenance if a response is
obtained; however data supporting their effectiveness for CD
is lacking. For patients with moderate to severe disease that
cannot be weaned off steroids or who do not respond to the
above therapies, immunomodulators (azathioprine,
6- mercaptopurine) and biologic therapies (anti-tumor necrosis factor [TNF] monoclonal antibodies).
Management may also be dictated by presenting symp-
toms. For example, patients presenting with obstructive symptoms may be managed with bowel rest and nasogastric tube
decompression. Patients presenting with an intra- abdominal
abscess may be managed with percutaneous drainage.
Surgery is indicated for medically refractory disease,
symptomatic stulas, neoplasia, or emergent situations
including massive hemorrhage, free perforation, or acute
obstruction. The most common indication for operation is an
obstructing stricture and surgical options include resection
with or without anastomosis, stricturoplasty, and bypass.
During surgery, preservation of healthy bowel is essential
and all normal intestine should be preserved.
Common Curveballs
• Presenting symptoms are a complication or extraintestinal manifestation of CD
– Example: pyoderma gangrenosum around ileostomy
in Crohn’s patient
• Differentiating between CD and ulcerative colitis
• Describing medical treatment options
• Know how to deal with multiple stricture, long segment
strictures and short strictures with different kinds of stricturoplasty (Heineke-Mikulicz, Finney, Jaboulay,
Michelassi)
• Know your options for Crohn’s stula (Seton, Fistulotomy,
mucosal ap, lift) and when to use them
• Patient has intra abdominal stula to another piece of
bowel (can primary repair vs. resect)
Clean Kills
• Failure to distinguish between CD and ulcerative colitis
• Failure to rule out infectious colitis or C. difcile
• Inappropriate use of surgical intervention prior to attempt
of medical therapy
• Incomplete knowledge of medical treatments and potential side effects
Summary
Crohn’s disease (CD) is a chronic inammatory intestinal disease that requires medical treatment. Surgery is
not curable and emergent surgery is rarely necessary
though may be indicated for refractory disease, hemorrhage, or perforations. When operating, preservation of
healthy bowel is essential.
Bibliography
Smith RK, Holubar SD. Medical therapy for Crohn’s dis-
ease. ASCRS textbook of colon and rectal surgery. ASCRS U; 2022. www.ascrsu.com/ascrs/view/
ASCRS- Textbook- of- Colon- and- Rectal- Surgery/2285041/all/
Medical_Therapy_for_Crohn’s_Disease
Steinhagen E, Bafford AC.Anorectal Crohn’s disease. ASCRS textbook
of colon and rectal surgery. ASCRS U; 2022. www.ascrsu.com/ascrs/
view/ASCRS- Textbook- of- Colon- and- Rectal- Surgery/2285042/all/
Anorectal_Crohn’s_Disease
Cannon LM, Fichera A. Crohn’s disease: surgi-
cal management. ASCRS textbook of colon and rectal surgery. ASCRS U; 2022. www.ascrsu.com/ascrs/view/
ASCRS- Textbook- of- Colon- and- Rectal- Surgery/2285043/all/
Crohn’s_Disease:_Surgical_Management
Ulcerative Colitis
JosephA.Sciacca, ArielleBrackett, andDavidPalange
32
Medical Management ofUlcerative Colitis
Concept
The goal of medical management of Ulcerative Colitis (UC)
is to provide steroid-free clinical remission with mucosal
healing. The approach to medical therapy is based upon the
patient’s age, extent of inammation, severity of symptoms,
and their response to treatment. It is important for a surgeon
to understand the appropriate medications and dosing
options available prior to discussion of surgical intervention
in refractory patients.
Way Question May BeAsked?
“A 28-year-old male presents to the emergency department
with a past medical history of ulcerative colitis. He has had
ongoing abdominal pain and loose bloody stools 2–3times
per day for the last two weeks. What would you like to do?”
How toAnswer?
History
• Onset of abdominal pain
• Onset of bloody bowel movements and amount
• Previous treatment history (Biologics, Steroids,
Immunomodulators, 5-Aminosalicylic acid compounds)
• Recent hospitalizations
• Recent antibiotic usage
• Anal receptive intercourse
• Family history
J. A. Sciacca · A. Brackett · D. Palange (*)
General Surgery, Christiana Care Health System,
Newark, DE, USA
e-mail: joseph.sciacca@christianacare.org;
arielle.brackett@christianacare.org;
david.palange@christianacare.org
• Extraintestinal manifestations
– Arthritis, ankylosing spondylitis, erythema nodosum,
pyoderma gangrenosum, primary sclerosing cholangitis (PSC)
Everything except PSC will improve with
colectomy
• Medication usage
– Anti-inammatories, corticosteroids, biologics
Physical Examination
• Vital signs (fever, tachycardia, sepsis)
• Abdominal examination (peritonitis?)
• Rectal examination (will always be involved in UC)
Diagnostic Tests
• Labs:
• CBC, BMP, Creatinine, Liver enzymes, Bilirubin (Total
and Direct)
• Albumin
• Fecal calprotectin
• C-reactive protein (CRP)
• Stool cultures, Ova and parasite studies, C.Difcile toxin
assay
• Consideration for a rectal swab (Rectal STDs)
• Imaging:
– Abdominal X-ray: limited use, rule out perforation /
toxic megacolon
– Computed tomography (CT): can identify areas of
inammation and identify complex anatomy
– Colonoscopy: proctitis/colitis beginning in the rectum
traveling proximally
Surgical Treatment
• Hospital admission
• Gastroenterology consulted for colonoscopy, as this is the
gold standard in patients with IBD
• Gastroenterology may not be available on your oral exam,
know how to perform a colonoscopy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_32
95
96
J. A. Sciacca et al.
• This question has the potential to morph into a colonoscopy procedure and end there
• CT imaging, if not already performed
• Two consecutive biopsies should be taken in the terminal
ileum, ascending, transverse, descending, sigmoid and
rectum
• In acute colitis settings, exible sigmoidoscopy is sufcient (exclude other causes of colitis and decrease perforation risk)
Endoscopic Pathology
• Diffuse (continuous), supercial, Crypt abscesses
• Must be differentiated from Crohn’s disease
Endoscopic Histopathology
• Microscopic appearance of UC on endoscopic biopsies is
characterized by crypt architectural distortion, with a diffuse transmucosal inammatory inltrate with cryptitis
and crypt abscess
Knowing Your Medical Treatment Options
• Low risk patients with mild-to-moderate UC→First line
treatment is 5-ASA derivatives
• Sulfasalazine and Mesalamine
• Severe UC Flares requiring hospitalization → IV
Corticosteroids
– Glucocorticoids—major concern is resistance and
dependency
Cushing’s symptoms
• If refractory to IV steroids→Second line agents such as
Cyclosporin or Iniximab can be used
• Time limited treatment: if patient continues to fail multiple agents over 7–10days will likely need surgery
• If symptoms are progressing despite treatment, toxic
megacolon develops or there is perforation, the patient will
need to be brought to the operating room for resection
– In addition to conventional UC (or less often CD) asso-
ciated with PSC, there appears to be a distinct phenotype among IBD patients with PSC (PSC-IBD).
PSC-IBD has been characterized as pancolitis with
rectal sparing, right- greater than left-sided inammation, higher rates of backwash ileitis, milder symptoms
despite endoscopic activity, and a higher medical treatment response rate
– Importantly, patients with PSC and colonic IBD also
have an increased risk of developing IBD-associated
mucosal dysplasia and colorectal cancer
• Interval colonoscopy timing for patients diagnosed with
UC (8years after dx)
– Performed every 1–2 years with high-denition
colonoscopy and random quadrant biopsy every
10cm
– Consideration of colectomy in high grade dysplasia
• Patient wishes to discuss homeopathic agents as a treatment option
– Probiotics, not FDA approved, can be helpful in treat-
ment of active UC
• Knowing side effects of 5-Aminosalicylate Compounds
and when to discontinue
– Sulfasalazine, although rare, can cause agranulocyto-
sis, pancreatitis and pneumonitis
– Mesalamine, again rare, can cause interstitial
nephritis
• Patients being treated with iniximab will eventually
develop antibodies and recur
– Review and know other biologic options
(Abdalimumab, Ustekinuman, Tofacitinib, etc.)
• If using Tofacitinib patient needs to be on DVT prophylaxis due to risk of clots
Clean Kills
Common Curveballs
• Backwash Ileitis: patients with inammation extending
to the cecum may also have inammation for a short distance of the terminal ileum; a patch of non-contiguous
cecal inammation is occasionally observed in UC
patients with more distal disease
• Primary sclerosing cholangitis: a chronic liver disease
characterized by bile duct inammation and often progresses to stricture formation in the bile ducts
– While ~75% of PSC patients will also be diagnosed
with IBD (predominantly UC), approximately 2–4%
of IBD patients will develop PSC
• Not making the diagnosis of UC
• Not ruling out infectious diarrhea or C. difcile and taking
out the entire colon
• Not performing sigmoidoscopy
• In medically refractory UC need to take biopsies to rule
out CMV
• Not treating toxic megacolon with steroids, antibiotics,
and serial examinations
• Not differentiating from Crohn’s disease
• -Not knowing the difference between UC and Crohn’s
disease
• -Not identifying the surgical indications for ulcerative
colitis (Perforation, toxic mega colon, failure of medical
management, malignancy, invisible dysplasia
32 Ulcerative Colitis
97
Summary
Patients with ulcerative colitis will present to the emergency department with abdominal pain and bloody diarrhea. Early surgical consultation is recommended and
knowing how to medically treat these patients is essential
to their outcomes. Being able to medically manage these
patients can help avoid an operation. Also knowing when
a patient is out of medical options and when to proceed
with an operation is crucial to the surgical management
of ulcerative colitis.
Medically Refractory Ulcerative Colitis/ Fulminant Colitis
Concept
Surgical intervention is indicated in the patient who fails
medical management and progresses to fulminant colitis or
develops a malignancy. It is estimated that 30% of patients
with UC will undergo surgery in their lifetime. Patients
with acute severe ulcerative colitis (ASUC) or fulminant
colitis can have extensive inammation beyond the mucosa,
through the colon wall which may lead to perforation. The
goal of surgery is removal of the entire colon and rectum (a
total proctocolectomy). Once the colon and rectum are
removed, two common options exist: an end ileostomy or a
restorative ileal anal pouch anastomosis (IPAA). The indication for these operations depends on patient presentation
and disease severity.
Way Question May BeAsked?
Presentation: “A 32-year-old male with recently diagnosed
ulcerative colitis 15months ago presents to the emergency
department with diffuse abdominal pain and bouts of bloody
loose stool. He admits that he is having 12 bloody bowel
movements daily. His symptoms have progressed over the
last 10 days. His gastroenterologist recently increased his
medical therapy to include prednisone 40mg daily. His vitals
are signicant for a temperature of 101F and tachycardia in
the low 100s. What would you like to do?”
How toAnswer?
• Recent antibiotic usage
• Anal receptive intercourse
• Family history
• Extraintestinal manifestations
– Arthritis, ankylosing spondylitis, erythema nodosum,
pyoderma gangrenosum, primary sclerosing cholangitis (PSC)
Everything except PSC will improve with colectomy
• Medication usage
– Anti-inammatories, corticosteroids, biologics
• Be familiar with the Truelove and Witts Criteria for
assessing severity of Ulcerative Colitis:
Feature Mild Moderate Severe
Stool frequency/day <4 4–6 >6 (mostly
bloody)
Heart rate <70bpm 70–90bpm >90bpm
Rectal bleeding Little Moderate Large amounts
Hemoglobin g/dL >11.5 10.5–11.5 <10.5
Weight loss % None 1–10% >10%
Pyrexia (>37.8) No No Ye s
ESR (mm/h) <20 20–30 >30
Albumin Normal 3.0–3.5 <3.0
Physical Examination
• Vital signs (fever, tachycardia, sepsis)
• Abdominal examination (peritonitis?)
• Rectal examination (will always be involved in UC)
Diagnostic Tests
• Labs:
• CBC, BMP, Creatinine, Liver enzymes, Bilirubin (Total
and Direct)
• C-reactive protein (CRP) should be drawn
• Fecal calprotectin
• Albumin
• Stool cultures, Ova and parasite studies, C.Difcile toxin
assay
• Consideration for a rectal swab (Rectal STDs)
• Imaging:
– Abdominal X-ray: limited use, but can identify perfo-
ration with pneumoperitoneum and colon dilation
– Computed tomography (CT): can identify areas of
inammation and identify complex anatomy, abscess,
or perforation
• Endoscopy:
– Flexible sigmoidoscopy to rule out CMV colitis in
patients not responding to medical management
History
• Previous treatments (Biologics, Steroids, Immunomodulators, 5-Aminosalicylate compounds)
• Duration of abdominal pain and bloody bowel
movements
• Recent hospitalizations or similar ares
Surgical Treatment
If Toxic Megacolon is suspected, then patients should be
considered critically ill. Their treatment course should
include:
98
J. A. Sciacca et al.
• Admission to an ICU
• NPO, NGT with IVF, ± TPN
• ± Blood transfusion
• IV Antibiotics
• IV Steroids (40–60mg IV daily of methylprednisolone)
• Close monitoring with serial abdominal examinations,
AXRs and labs
– The above applies to patients with a dilated colon and
no signs of sepsis
Failure to improve with a trial of conservative manage-
ment is an indication for an urgent colectomy:
• Signs of sepsis: Fevers, tachycardia or progressive
abdominal pain
In the era of biologic therapy, the current standard of care
in patients with Acute Severe Ulcerative Colitis (ASUC)
refractory to steroids includes inpatient Iniximab or
Cyclosporin. Prior to these medications, urgent colectomies
were standard of care.
Flexible sigmoidoscopy must be performed to rule out
CMV colitis and C.Diff colitis in patients not responding to
medical management.
Surgical Options andConsiderations
1. Total abdominal colectomy with end ileostomy
• Patients in extremis will need staged operations beginning with a total abdominal colectomy with end
ileostomy
• Ileostomy site should be marked out pre-operatively
with wound ostomy nursing if available
• Indicated in the emergent setting
• Rectum can be left as a Hartmann stump
• Consider a mucous stula from rectal pouch to avoid
rectal stump leak (if worried about staple line
integrity)
2. Ileal pouch anal anastomosis (J pouch)
• Can be performed as a staged operation
– Staging depends on patient presentation, medica-
tions (steroids, TNF-a), nutritional status, comorbidities and technical issues intra-operatively
(tension on anastomosis)
• If a patient was treated in the emergent setting with
total abdominal colectomy and end ileostomy, the
patient will need to recover from the initial surgery
and nutrition will need to be optimized before consideration of J pouch
• In patients operated on in extremis, a 3-stage procedure is the most common
– Total abdominal colectomy with end ileostomy
– Proctectomy with formation of J pouch and loop
ileostomy
– Takedown of loop ileostomy
• In patients operated on for malignancy or dysplasia, a
2-stage procedure can be performed
– Total abdominal colectomy with formation of J
pouch and loop ileostomy
– Takedown of loop ileostomy
– Remember to perform a leak test at the conclu-
sion of the case
Common Curveballs
• Interval colonoscopy timing for patients diagnosed with
UC (8years after dx)
– Performed every 1–2years with high-denition colo-
noscopy and random quadrant biopsy every 10cm
– Consideration of colectomy in high grade dysplasia
(vs SCENIC guidelines and intensive screening)
• J pouch surveillance every 1–3years with biopsy of pouch
and rectal cuff
• If a diverting ileostomy is created, knowing the timeline
for appropriate reversal when asked
– 2–3months
• Know how to treat rectal stump leak if left in situ during
initial operation, consider mucous stula to from rectal
pouch to avoid this complication
– This can be left as a subcutaneous staple line to prevent
intra-abdominal leak
• Be able to handle anastomotic complications including J
pouch leak and sinuses
• Recognizing, diagnosing, and treating pouchitis
– Differentiate between ulcerative colitis are from rec-
tal cuff vs pouchitis
– Bacterial overgrowth and stasis
– Pouch endoscopy
– Antibiotics and continuous drainage
• Tall or obese males more likely to have issues with the J
pouch not reaching, intra-operatively
– Apex of the pouch should reach the pubic symphysis.
This is commonly used to judge if a pouch will reach
– If it does not reach, take a step wide approach
Mesentery dissected away from duodenum
through D3.
Relaxing incisions in the mesentery along the
SMA
Selective ligation of arterial branches (Clamp for
15min before dividing to assess viability)
If still does not reach, suture pouch into the pelvis and return to OR in 3–6months
• After performing a J Pouch, the patient will develop anal
pouch stula
32 Ulcerative Colitis
99
– Be very suspicious for Crohn’s disease
– Pouchoscopy with biopsies
Clean Kills
• Not ruling out C.Difcile or CMV in the initial workup
• Not making the diagnosis of UC
• Not ruling out infectious diarrhea or C. difcile and taking
out the entire colon
• Not performing sigmoidoscopy
• Not treating toxic megacolon with steroids, antibiotics,
and serial examinations
• Not differentiating from Crohn’s disease; examining the
small bowel for inammation
• Not knowing the difference between UC and Crohn’s
disease
• Performing rectal dissection while patient is in extremis
or critically ill
Summary
Patients with ulcerative colitis who have failed medical
management, progressed to fulminant disease or have an
identied malignancy, meet criteria for surgical intervention. Around 30% of UC patients will have surgery for their
disease in their lifetime, and many of them ask for surgery
sooner in their disease course. The surgical interventions
are typically performed in a staged fashion depending on
the indication for surgery and the state of health the patient
presents. The goal of surgical intervention is for eventual
removal of the colon and rectum. Following surgery, it is
important to understand the complications that may arise,
and appropriate surveillance is needed.
Bibliography
Clinical Decisions in Surgery Decision making and Operative
Technique.
https://www.ascrsu.com/ascrs/view/ASCRS- Textbook- of- Colon- and-
Rectal- Surgery/2285038/all/Inammatory_Bowel_Disease:_Pathobiology.
https://www.ascrsu.com/ascrs/view/ASCRS- Textbook- of- Colon- and-
Rectal- Surgery/2285039/all/IBD_Diagnosis_and_Evaluation.
https://www.ascrsu.com/ascrs/view/ASCRS- Textbook- of- Colon- and-
Rectal- Surgery/2285044/all/Ulcerative_Colitis:_Surgical_Management.
Zenker’s Diverticulum
MichaelPryor andVictoriaSharp
33
Concept
Zenker’s is a pulsion diverticulum. The lower pharyngeal
constrictor muscle (thyropharyngeus) contracts against an
unyielding cricopharyngeus muscle creating an acquired, or
false, diverticulum that will typically get larger over time.
This is characterized by mucosal out-pouching of the esophageal wall between these muscles on the left posterolateral
side within Killian’s triangle.
Way Question May BeAsked?
“A 73-year-old male presents on referral from his PCP complaining of trouble swallowing with sensation of food getting
stuck in his throat.” Rarely will you get the patient with obvious bad breath, dysphagia to solids and liquids, regurgitation
of undigested food, and gurgling in the neck.
How toAnswer?
Must work through an algorithm of dysphagia and rule out
achalasia, motility disorders, and cancer.
History
• Sensation of food getting stuck in throat/food bolus
• Chronic cough or respiratory infections from aspiration
• Intermittent dysphagia
• Halitosis (bad breath)
• Regurgitation of food/GERD/Barrett’s
• Voice changes
M. Pryor
General Surgery, Trinity Health Ann Arbor, Ypsilanti, MI, USA
e-mail: mike.pryor@trinity-health.org
V. Sharp (
Trauma, Acute, and Critical Care Surgery, Trinity Health Ann
Arbor, Ypsilanti, MI, USA
e-mail: victoria_sharp@ihacares.com
*)
• Retrosternal pain
• Gurgling sound in neck
• Weight loss
• Smoking history
Physical Examination
• Examine neck and lymph node basins—will never feel
the diverticulum but may feel a mass indicative of
malignancy.
Diagnostic Tests
• Barium Esophagram—Lateral views are critical. EGD or
manometry are not needed to diagnose.
• CXR—if concerned for aspiration.
• Possible assessment of the preoperative status (pulmonary, cardiac, and renal evaluation).
Treatment Options
1. Open: If the patient is a poor endoscopic candidate, fails
endoscopic intervention, <2 cm or >5 cm diverticulum
size.
• Endoscopic evaluation if feasible with bougie placement to prevent narrowing.
• Left cervical incision over anterior border of SCM or
transverse at level of cricoid cartilage.
• Diverticulum is in the plane between carotid sheath
and trachea.
– Be mindful of the recurrent laryngeal nerve.
• Always perform a cricopharyngeal myotomy—gentle
cephalad traction on the diverticulum will expose
bers of the cricopharyngeus muscle, which are
divided and bluntly dissected from the underlying
mucosa and continued onto the esophagus for several
centimeters—Suspend or Resect the diverticulum.
• May leave the diverticulum alone if <2cm, although
myotomy is still encouraged.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_33
101
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M. Pryor and V. Sharp
• Diverticulopexy:
– May be performed for high-risk of leak patients
(elderly, large diverticula).
– Pexy to posterior pharynx with absorbable suture so
that mouth of diverticulum is dependent as opposed
to prevertebral fascia to allow for movement with
swallowing.
Diverticulectomy: Good tissue or >5cm sac. Will likely
be pushed to perform one on exam.
– Identify normal pharyngeal/esophageal tissue.
– Staple device or sharply divide then perform two-
layer imbricating closure.
Always drain the incision.
2. Endoscopic Stapling: Patient must be able to undergo
hyperextension of the neck and diverticulum must be
2-5cm.
• A exible endoscopy is performed.
• Make sure scope is in the true lumen—Scope tends to
pass preferentially into the diverticulum due to the
tightness of the cricopharyngeus muscle.
• Pass a guide wire through the scope and into the
stomach.
• The exible scope is removed and replaced with the
rigid endoscope device.
• The diverticulum should be irrigated and
measured.
• A traction stitch is then placed in the septum using the
endostitch.
• An EndoGIA stapling device is then passed through
the rigid endoscope to divide the septum.
– The septum should be divided down to the bottom
of the diverticulum.
– Multiple rings of the stapler may be required.
• A completion exible endoscopy should be performed
to inspect the staple line and to make sure the entire
septum has been divided—keep in mind this does not
remove the actual diverticulum.
Common Curveballs
• Patient develops a leak or wound infection post-op:
– Open the incision to drain the wound infection/abscess
that may develop following a leak.
• Performing a pexy leads to perforation of the
diverticulum:
– If not septic/unstable, perforation can generally be
treated conservatively with restricted PO intake and
antibiotics.
– The neck incision may be opened to drain any neck
abscess that may develop.
• Injury to the recurrent laryngeal nerve is identied
post-op:
– Unilateral nerve injury may be asymptomatic, or the
patient may develop hoarseness.
If the nerve has not been completely transected,
symptoms will generally improve over time with
therapy. Breathing problems are rare with unilateral
injury.
– Transected nerves identied intra-operatively > repair
immediately.
– Injuries identied post op = repair after 6 months if
symptoms have persisted.
• Diverticulectomy leads to narrowing/stricture of the
esophagus:
– Balloon dilation or stenting may be attempted if the
patient is symptomatic.
– If identied outside of the early post-op period, the
stricture should be biopsied to rule out cancer.
• Injury to esophagus intra-op:
– A primary repair should be performed. If a long seg-
ment of the cervical esophagus is involved an SCM
ap can be performed to reinforce the repair.
Clean Kills
• Forgetting to leave a drain.
• Not describing whichever procedure you’re going to perform properly.
• Forgetting to perform the cricopharyngeal myotomy,
must be complete to reduce recurrence.
• Forgetting to perform UGI or not performing prior to
EGD.
Summary
Zenker’s diverticula are rare and occur most commonly
in males in the sixth to eighth decade of life. It is a
Pulsion diverticulum created by diminished upper
esophageal sphincter opening and increased hypopharyngeal pressure, leading to development of a false
diverticulum. The most common symptoms are dysphagia, regurgitation of undigested food particles, and halitosis. Recurrent upper respiratory infections from
chronic aspiration events can lead to life threatening
respiratory insufciency.
Upper GI series should be the rst diagnostic test per-
formed when suspected due to risk of perforation with
EGD.Some patients will present with complaints related
to other upper GI pathology. There is a particularly high
association of this disorder with hiatal hernia and
GERD.Thus, complete upper gastrointestinal pathology
work-up should be completed with EGD, manometry,
and pH monitoring as well.