return to: Zenker's Diverticulectomy

ANATOMY

All 3 constrictors pass around and insert into a midline raphe on the posterior pharynx and vary in where they originate. This raphe suspends the pharynx from the base of skull at the pharyngeal tubercle, which is a palpable bump.

1. Superior Constrictor-
   1. From pterygomandibular raphe, posterior to buccinator (also to sphenoid bone).
2. Middle Constrictor-
   1. From the greater and lesser horns of the hyoid bone, and a portion of the stylohyoid ligament deep to hyoglossus.
3. Inferior Constrictor-
   1. From thyroid cartilage and small area of adjacent cricoid. (the lower portion is sometimes called the cricopharyngeus)

Structures entering pharynx pass through gaps between the muscles

1. above superior constrictor - eustachian tube and levator veli palatine muscle
2. between superior and middle constrictor - stylopharyngeus muscle blends into pharyngobasilar fascia, and the Glossopharyngeal travels along this muscle.
3. below inferior constrictor (cricopharyngeus part) - the recurrent laryngeal nerve enters the larynx
4. The mucous membrane may herniate through any of these gaps due to increased pressure. These outpouchings are referred to as Zenker Diverticuli (pl). Zenker diverticuli are usually located in the posterior hypopharyngeal wall. Small Zenker diverticuli may not cause symptoms but larger ones may collect food and obstruct the esophagus.

GENERAL CONSIDERATIONS

1. The different diverticula
   1. Zenker's: most common form, originates posteriorly below the inferior constrictor and above the cricopharyngeus muscle. They then descend into the retropharyngeal space.
      1. On swallow study, located more posteriorly and will often have a cricopharyngeal bar present.
   2. Killian-Jamieson's:  arises inferior to cricopharyngeus; resides anterolateral to the esophagus - inferior to the transverse portion of the cricopharyngeus muscle and lateral to the longitudinal muscle of the esophagus (LEM), where the LEM inserts into the inferior border of the cricoid cartilage.
      1. Only reports of right-sided KJD are in cases where they are bilateral, as unilateral cases have been found exclusively on the left side. The literature suggests that an open approach is superior in these cases to avoid RLN injury (Undavia et al 2013).
   3. Laimer's: located inferior and posterior to the cricopharyngeus muscle; inverted triangle of circular esophageal muscle in area of sparse longitudinal esophageal muscle fibers

ANESTHESIA CONSIDERATIONS

1. Oral intubation with laser safe tube to  
   1. General anesthesia with intubation
2. Paralysis: Although initial exposure of the diverticulum may be improved by paralysis, the relaxation of the cricopharyngeus may complicate the treatment measures.

OPERATIVE PROCEDURE

Informed written consent was obtained. The patient was then transferred to the operating room and placed in the supine position. He was endotracheally intubated using a laser safe tube with the tube taped under the right oral commissure. The bed was then rotated 90 degrees. He was positioned appropriately with the head slightly up. A mouth guard was placed and a rigid esophagoscopy was performed. A telescope was passed for digital documentation of the exam. The distal extend of the rigid esophagoscopy did not demonstrate any significant pathology. The rigid esophagoscope was then slowly removed in conjunction with the telescope. The mucosa appeared normal throughout. At the level of the cricopharyngeus, a diverticulum was encountered with a good view of the party wall between the normal esophagus and the diverticulum. Next, the Weerda diverticuloscope was placed with the superior blade of the diverticuloscope positioned in the esophagus and the inferior blade was positioned in the diverticulum, thus allowing for adequate exposure of the cricopharyngeal bar. At this point in time, a small vertical mucosa cut was created using the CO2 laser on a setting of 8 watts on superpulse continuous mode. At this point in time, the underlying cricopharyngeus muscle was exposed. Laryngeal spreaders were used to expose the underlying cricopharyngeus muscle. With dissection of mucosa from the the muscle, the muscle was transected using the CO2 laser to good effect. The diverticulum was decompressed through by maneuver. At this point in time, the Weerda laryngoscope was removed, and the case was brought to a close. The patient was then returned to Anesthesia and transferred to the PACU in good condition.

POSTOPERATIVE CARE

1. Nil per os: 3 days 
   1. nasogastric tube feeds until then
   2. keep Penrose drain in place until NGT removed on POD #4
   3. can start clear fluids at the beginning of POD 3 and continue for 24 hours, can start mechanical soft diet later in same day if PO intake well tolerated
   4. maintain NGT until POD 4 (but stop tube feeds) to ensure adequate PO intake
2. Only one dose of perioperative antibiotics

SAMPLE DICTATION

After informed written consent was reviewed, and the patient was brought back to the operating room by Anesthesia. He was placed in the supine position and he was uneventfully intubated. The table was turned 90 degrees. After a multidisciplinary time-out, the procedure was begun with placement of moist gauze over the upper maxillary alveolar process as the patient was edentulous. A cervical esophagoscope was then placed transorally with identification of a large diverticulum that measured approximately 5 cm in depth posterior to the esophagus with a notable cricopharyngeal bar. Esophagoscopy continued distally down to the gastroesophageal junction with no other abnormalities noted. The diverticulum itself was suctioned free of a variety of debris. A 42-French Maloney dilator was placed without effort into the true esophagus and advanced down. The decision was reached to perform an open diverticulectomy. His left neck was prepped and draped in sterile fashion. An incision was designed at the level of the cricoid at approximately 2 cm in length, lateral to midline. A #15 blade was used to incise down through the platysma. Flaps were raised in a subplatysmal fashion, inferiorly to the level of the clavicle and superiorly to the thyroid notch. Blunt and sharp dissection was used to dissect down lateral to the strap muscles and medial to the carotid sheath. We encountered the carotid and vagus nerve and left them undisturbed. We were able to establish an avascular plane down to the prevertebral fascia. We then were able to identify the constrictor muscles on the posterior aspect of the thyroid cartilage. We were able to rotate the thyroid cartilage with excellent exposure of what appeared to be a smooth diverticulum just to the left of midline and lying posterior to the visceral compartment. With a Kitner and blunt dissection, we were able to skeletonize the diverticulum in a cephalad direction. We rolled the thyroid cartilage towards the right once more, with identification of the cricopharyngeus muscle. A Jake hemostat was then placed deep to the cricopharyngeus, and with bipolar cautery, a one centimeter wide area of cautery was performed, and this was lysed with Stevens scissors. This was performed in approximately 1.5 cm of length of muscle in a craniocaudal dimension. Care was exercised to avoid injury to the recurrent laryngeal nerves. The left-sided recurrent laryngeal nerve was clearly identified early in the dissection and easily preserved. We were able to place an Allis on the distal aspect of the diverticulum, and with lateral traction, a 45 mm x 3.5 mm TA Auto Suture stapler was then placed at the base of the diverticulum, adjacent to the esophagus. It was engaged, and the staple line closure was performed. The diverticulum was divided with a #15 blade scalpel with the stapler still in place. The wound was copiously irrigated normal saline. A Corpak 12-French feeding tube was then placed in the right naris and passed atraumatically under direct visualization, using a MAC laryngoscope. It was also palpated in the cervical esophagus as it passed through. The neck was closed in layers, first approximating the platysma with interrupted 3-0 Vicryl sutures, followed by placement of a drain from the prevertebral fascia out of the wound. This was a 1/2-inch Penrose drain. This was sutured at the medial most aspect of the incision. The superficial layer was closed with running 4-0 nylon. The Maloney dilator, of course, was removed prior to placement of the Dobbhoff feeding tube. The gingiva and lips were examined and were free of any injury. He was turned back over to Anesthesia, having tolerated the procedure well.

REFERENCES

Ann Otol Rhinol Laryngol.  2011 Dec;120(12):796-806. Management of Zenker's diverticulum in the endoscopic age: current practice patterns. Bock JM et, Van Daele, D

Undavia et al.: KJD and an Open Transcervical Approach. Laryngoscope, 123:414–417, 2013