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 

      • See 2012: Open surgery for Zenker's diverticulum

  • Cricopharyngeal myotomy (CP) 

    • Complete CP myotomy should be performed during the open approach 

• 2012: Open surgery for Zenker's diverticulum

• 2012: Principles of surgical treatment of Zenker diverticulum

• 2013: Zenker's diverticulum: exploring treatment options

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 

      • Iowa Protocols - Esophageal Perforation Treatment

    • Long term

      • Failure of symptomatic improvement and recurrence of dysphagia

Pearls & Pitfalls

High-Yield

Links

• eMedicine: Zenker Diverticulum

• eMedicine: Cricopharyngeal Myotomy

• UTMB Grand Rounds - Zenker’s Diverticulum

• Iowa Protocols - Zenker's Diverticulum - Open Approach

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - SURGERY FOR PHARYNGEAL POUCH / ZENKER’S DIVERTICULUM