We commonly employ a five-port approach to VATS resection of epiphrenic diverticula. The port placements are identical to the ports we employ for minimally invasive esophagectomy. Specifically, the surgeon works from the posterior ports, which include an infrascapular tip 5-mm port and a 10-mm port in the 9th interspace along a line parallel to the infrascapular tip port. The remaining three ports are assistant ports and include a 10-mm camera port in the 9th interspace along the posterior axillary line, a 5-mm port for endoscopic suction in the 7th interspace in the midaxillary to posterior axillary line, and a lung retraction 10-mm port in the 5th interspace in the posterior axillary line. See FIG 1 for ideal placement of ports.³

Upon entering the chest, the inferior pulmonary ligament is divided and the lung is retracted superiorly and anteriorly.

A diaphragm stitch is placed through the central tendon of the diaphragm with a 48-in 0-Surgidac Endo Stitch. It is brought out the right flank at the level of the inferior diaphragm insertion using an endoscopic Endo Close device. Tension is applied to the retraction stitch to retract the diaphragm caudally, exposing the distal esophagus and esophageal hiatus.

Using sharp dissection with a heat source such as an ultrasonic scalpel, the mediastinal pleura overlying the esophagus is opened. As much of the pleura as possible is kept intact so that it may be reapproximated over the repair at the end of the procedure. As such, the pleura is gently dissected away from the esophagus. Opening
of the mediastinal pleura from the diaphragm up to the azygous vein is beneficial, as it will be necessary for the performance of a long myotomy. The azygous vein can be divided as needed with an endoscopic stapler.

Once the pleura has been opened adequately, esophageal mobilization is carried out. If an ipsilateral approach is taken to the diverticulum (right VATS for a right-sided diverticulum), minimal mobilization is needed. However, if the diverticulum protrudes on the contralateral aspect of the esophagus, the esophagus must be mobilized so that it may be rotated to provide adequate exposure for dissection of the diverticulum and its neck.

A Penrose drain may be used to encircle the esophagus and aid in esophageal mobilization.

Both vagus nerves should be identified and preserved whenever possible.

It is necessary to expose the entire diverticulum and its neck. The diverticulum may be grasped with an endoscopic Babcock grasper (Snowden-type endoscopic forceps). Alternatively, a long stitch may be placed in the apex of the diverticulum to aid with retraction during dissection. Subsequently, the diverticulum is circumferentially dissected free from its surrounding attachments. It is not uncommon for there to be significant inflammatory type adhesions from the diverticulum to surrounding structures. It is essential to dissect the surrounding esophageal muscle fibers down to the neck of the diverticulum. This maneuver is critical in order to ensure complete resection of the diverticulum at the time of stapling. A common technical error is failure to expose the true neck of the diverticulum, which subsequently results in improper positioning of the stapling device and therefore leaves a residual diverticulum.

Once the neck of the diverticulum is clearly visualized, either the endoscope or a 48- to 54-Fr bougie should be inserted into the esophagus beyond the GE junction. This prevents narrowing of the esophageal lumen during stapling of the diverticulum. If difficulty is encountered passing the bougie, intraoperative upper endoscopy should be performed and a wire passed distally through the true lumen of the esophagus into the stomach. The bougie may then be passed over the wire to minimize risk of perforation.

With minimal tension on the diverticulum, the stapling device is positioned along the base (neck), parallel to the longitudinal axis of the esophagus (FIG 2).

The diverticulum is then transected with a reticulating endoscopic stapler. The authors prefer to use a vascular load for transection of the mucosa and submucosa that comprises the diverticulum.

It is preferable to perform the myotomy at least 90 degrees away from the diverticular staple line if possible. The longitudinal esophageal muscle fibers are incised initially with either an ultrasonic scalpel or hook cautery along the direction of the fibers. Alternatively, the myotomy may also be started with a blunt technique by pulling apart the longitudinal muscle fibers. Once the underlying circular muscle fibers are exposed, they are sharply divided. It is critical to lift the circular muscle fibers away from the underlying mucosa to avoid perforation of the mucosa layer (FIG 3).

Attempt to preserve the main vagal trunks while performing the myotomy.

The total length of the myotomy should extend several centimeters (3 to 5 cm) above the proximal extent of the diverticulum. Distally, the myotomy should extend to or across the GE junction, depending on the preoperative manometry results and the underlying pathologic diagnosis. For example, an LES that has a normal resting pressure and normal relaxation may not require myotomy across the GE junction, preserving its natural antireflux function. If the patient has achalasia, the myotomy should ideally extend to 3 cm below the GE junction, carrying the myotomy onto the sling muscle fibers of the gastric cardia.

The muscle layer is dissected laterally off the underlying mucosa for a short distance in the submucosal plane to prevent potential healing of the myotomy site (muscle reconstitution).

The integrity of the myotomy and diverticulectomy sites are submerged under saline and upper endoscopy with insufflation of air is done to check for leaks. Intraoperative mucosal perforations are repaired with interrupted absorbable suture. The muscle layers are then reapproximated over the diverticulectomy staple line with interrupted 2-0 Surgidac Endo Stitch.

The mediastinal pleura may also be loosely reapproximated over the esophagus with interrupted 2-0 Surgidac Endo Stitch for additional protection of the staple line.

The need for an antireflux procedure should also be addressed at this point, depending on the patient’s preoperative reflux symptoms and motility studies.1,4 If the patient carries a diagnosis of achalasia, an antireflux operation should be considered. There are several options at this point. If performing the case from a left VATS, one may attempt a Belsey Mark IV fundoplication. This can be quite challenging and technically demanding from a VATS approach (traditionally performed via left thoracotomy). A second option is to combine VATS with laparoscopy and perform a standard laparoscopic Dor or Toupet (partial) fundoplication. Partial fundoplications are favored in the setting of esophageal motility disorders, as a complete (Nissen) fundoplication may lead to obstruction of the dysmotile esophagus and recurrent diverticula. Lastly, one could forego the antireflux procedure and treat any reflux symptoms with proton pump inhibitors (PPI), opting to perform a fundoplication selectively at a later time depending on patient symptoms and response to medical therapy.

Once hemostasis is achieved, a pleural drain (chest tube, Blake drain, or pigtail catheter) is placed.

A Jackson-Pratt (JP) drain is also placed along the posterior mediastinum near the diverticula staple line to control any leak that can potentially occur postoperatively.

Intercostal bupivacaine is injected for analgesia.