Zenker’s diverticulum is primarily a condition of the elderly and is twice as common in men. Dysphagia for solid food and regurgitation of undigested food are the most common symptoms and are typically present. Halitosis, noisy swallowing or “gurgling” after deglutition, and globus sensation are also common. Aspiration may also result from this condition, and it may manifest as a mild nocturnal cough, morning hoarseness, or new onset adult bronchospasm caused by repeated laryngeal penetration and irritation and, on rare occasion, present as chronic lower respiratory tract infection or even lung abscess. Despite the association among hiatal hernia, gastroesophageal reflux, and Zenker’s diverticulum, only a few patients present with severe heartburn and rarely do they require surgical correction of their reflux.

Endoscopic management may not be the preferred procedure in some patients due to anatomic constraints. Difficulty may be encountered in placing the diverticuloscope in patients with retrognathia, limited jaw mobility, prominent incisors, or rigid cervical kyphosis that limits neck extension. In a prospective study of factors predicting endoscopic exposure and repair of Zenker’s diverticulum, the endoscopic procedure was unsuccessful in 30% of patients. Patients with short necks, high body mass index (BMI), and decreased hyomental distance were less likely to have successful endoscopic repair, and the authors advocate an open approach in such patients. In addition, the size of the diverticulum on barium esophagogram should be assessed because small diverticula (<3 cm) are generally not amenable to stapling. A small pouch limits access of the stapler anvil and prohibits the attainment of an adequate length of myotomy. Diverticula >6 cm should also be managed with an open approach because endoscopic stapling results in a large pharyngeal cavity that does not empty completely. This information is helpful in preoperative discussions with the patient concerning the likelihood of conversion to an open procedure. All patients should be prepared and give consent for an open procedure in the event that endoscopic instrumentation proves unfeasible or a complication is encountered. Patients are instructed to limit their diet to clear liquids the day before surgery.

Although many cervical operative procedures may be performed under local anesthesia, general endotracheal anesthetic is suggested for this procedure, along with the usual preincision antibiotic prophylaxis.

After induction of general anesthesia, a shoulder roll is placed to achieve neck extension in the standard position for rigid esophagoscopy. An upper jaw dental guard is placed. Direct endoscopy is performed using a lighted suspension laryngoscope. The esophageal lumen, diverticular lumen, and their common wall are visualized. The distal blades are opened slightly to enter the esophagus anteriorly and the diverticular lumen posteriorly. The distal blades of the instrument are opened, keeping the common wall between the esophagus and diverticulum centered in the scope’s aperture. The proximal scope is then widened, and the laryngoscope is attached to a suspension system to allow for bimanual instrumentation during the stapling procedure. A 0-degree bronchoscopic telescope attached to an endoscopic camera is then inserted laterally through the laryngoscope. The pouch is examined to exclude malignancy and to assess the depth of the pouch and length of the septum. A 30-mm linear GIA stapler is then introduced through the laryngoscope, and its jaws are positioned on the common wall with the longer end containing the staple cartilage within the esophageal lumen. The position of the jaws is confirmed using the telescope. If the position of the jaws is in question, the stapler is opened and the device reapplied. If necessary, traction sutures can be placed laterally in the common wall using an endosuture device and used to help pull the common wall into the jaws of the stapler. If proper positioning of the stapler cannot be confirmed before firing,
the minimally invasive approach cannot safely be performed and should be abandoned in favor of an open procedure. Once proper position is confirmed, the stapler is fired and removed. The stapler divides the common wall, including the cricopharyngeus muscle, between the diverticulum and esophagus and closes the wound edges with a triple row of staples on each side. The divided edges of the septum should retract laterally revealing an open esophageal lumen. The cut edges should be inspected to ensure hemostasis. Should a significant septum and diverticular sac still be present, a second stapler application should be performed in a similar manner. Once the septum is completely divided and hemostasis is confirmed, the procedure is terminated. Patients are offered a liquid diet the following day, and if fluids are tolerated, they are advanced to a soft diet and discharged on the second postoperative day. All patients should have a chest radiograph postoperatively to exclude perforation, which more than likely would manifest as air in the retropharyngeal space or mediastinum.