Video immediately condensed (30 second video) from real-time; 5 minute 20 second video further below 

real time video below (5 minutes and 20 seconds)

Video 1: Placement of expanding Zenker's diverticula scope followed by small laser incision in mucosa and dissection of cricopharyngeus.

Dissection of cricopharyngeus. Zenker's scope placed incision made

Video 2: Laser transection of cricopharyngeus.

Zenker's diverticulectomy

 Video 3: Final result with removal of diverticuloscope

Zenkers final

GENERAL CONSIDERATIONS

Indications

1. Types of 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. 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. Only reports of right-sided KJD are in cases where they are bilateral, as unilateral cases have been found exclusively on the left side (see 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 CONSIDERATION

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 extent 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 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.

REFERENCES

Ann Otol Rhinol Laryngol. 2009 Jul;118(7):512-8.Links. Endoscopic carbon dioxide laser Zenker's diverticulotomy revisited.Kos MP, David EF, Mahieu HF.

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