Zenker’s diverticulum is an outpouching of the pharyngoesophagus. It is considered a pulsion diverticulum. The resection can be performed through an open or endoscopic approach.
Indications for Zenker’s Diverticulectomy
Dysphagia (difficulty swallowing)
Partial obstruction
Aspiration of fluid causing coughing spells
Choking sensation
Pain on swallowing
Diagnosis of Zenker’s Diverticulectomy
Barium swallow – this test will show an outpouching from the posterior wall of the esophagus distal (below) to the inferior constrictors of the pharynx and proximal (just before) the cricopharyngeus muscle. The pouch usually lies to the left of the esophagus.
Click the image to view a fluroscopic barium swallow.
The Zenker’s diverticulum is the sac-like structure seen filling at 3 o’clock.
Preoperative Preparation in Zenker’s Diverticulectomy
The patient is instructed to take a clear liquid diet for two days before surgery to allow the pouch to be empty of food particles. Some surgeons have their patients gargle vigorously with an antiseptic mouthwash before surgery. Broad-spectrum preoperative antibiotics are usually administered.
Incision – open approach
The patient to receive Zenker’s diverticulectomy is placed supine (face up) on the operating table with a roll placed under the shoulders to hyperextend the neck. The incision is made along the anterior (front) border of the sternocleidomastoid muscle.
Surgical Details of the Procedure
1. A No. 10 scalpel is used to make the incision through the skin along the anterior border of the sternocleidomastoid muscle.
2. Bovie cautery is used to incise the subcutaneous tissue.
3. The platysma is divided using the Bovie cautery.
4. Care must be taken to not transect or injure the cervical cutaneous nerve that runs 2-3 cm below the angle of the jaw.
5. The fascial attachments of the sternocleiodmastoid are released by using Bovie cautery.
6. The sternocleidomastoid is retracted laterally (away from the midline.)
7. Two clamps are placed on he omohydoid muscle running horizontally across the lower margin of the incision before it isdivided with the Bovie cautery.
8. The ends of the omohyoid are then ligated with 0 silk ties.
9. The proximal omohyoid remnant is retracted medially and the distal omohyoid remnant is retracted laterally.
10. The superior thyroid artery is visualized in the cephalad (toward the head) portion of the wound as the omohyoid is retracted.
11. This artery is clamped and divided with 2-0 silk ligatures placed.
12. The fascia containing the trachea, esophagus, and thyroid gland is visualized medial to the carotid sheath and is incised using the Metzenbaum scissors.
13. Blunt dissection is used to visualize the posterior surfaces of the esophagus and pharynx.
14. If adhesions are present secondary to inflammation and the fascial planes are obscured, a rubber catheter is placed down the esophagus with gentle insufflation of air to distend the diverticulum.
15. The diverticulum is dissected free until the neck has been visualized and is freely mobile.
16. Care must be taken to visualize both recurrent laryngeal nerves to gently dissect from the tissue surrounding the diverticulum and to then retract them to avoid injury.
17. Many surgeons now place a GIA or TA endostapler across the neck of the diverticulum and staple off the lumen and then transect the pouch.
18. Alternately, the diverticulum can be resected with a knife and the defect hand-sewn. This is accomplished by placing stay sutures of vicryl or silk at the 3 o’clock and 9 o’clock positions.
19. An incision is made in the mucosa and the diverticulum is transected cirumferentially distal to the stay sutures.
20. A nasogastric tube is placed past the opening in the esophagus to insure that the closure does not narrow the lumen.
21. A two layer closure of the esophagus is performed with the inner mucosa layer closed with interrupted 4-0 suture with the knot on the inside.
22. The outer layer of closure in the muscle defect between the inferior constrictors and the cricopharyngeus muscles is done with 4-0 interrupted suture.
23. The wound is irrigated and some surgeons place a small silastic drain over the repair.
24. The omohyoid is then reapproximated with 2-0 interrrupted sutures.
25. The platysma is then reapproximated using 2-0 interrupted sutures.
26. The skin is closed using 4-0 Monocryl sutures in a subcuticular manner
Postoperative course in Zenker’s Diverticulectomy
The Zenker’s diverticulectomy patient is kept NPO (nothing by mouth) for three days with fluids and tube feedings given through the nasogastric tube. The drain is removed on the second postoperative day usually. Some surgeons perform a gastrograffin swallow before resuming feedings. The patient is started on clear liquids and advanced as tolerated. Antibiotic coverage is usually for the first 24 hours postoperatively.