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Thoracoscopic management of esophageal diverticula
INTRODUCTION
Esophageal diverticula are uncommon and typically cause dysphagia, regurgitation, recurrent aspiration, or chest pain. Most clinically relevant esophageal diverticula are of the “pulsion” variety and result from an underlying esophageal motility disorder, most commonly achalasia. They occur over the mid to distal esophagus in an “epiphrenic” location. These are “false” diverticula, as they do not contain all layers of the esophageal wall, but rather only the mucosa and submucosa protruding through the circular and longitudinal muscles. “Traction” diverticula are the result of externally placed tension on the esophagus, typically due to mediastinal lymphadenopathy from infectious etiologies such as tuberculosis or histoplasmosis. These are “true” diverticula consisting of all esophageal layers, though are rarely of clinical consequence. For the purposes of this discussion, only pulsion diverticula are considered.
Traditional surgical treatment of esophageal diverticula has been the so-called triple-treat operation, consisting of diverticulectomy, esophageal myotomy, and partial fundoplication performed by an open left thoracotomy (refer to Chapter 43, “Left thoracic approach to esophageal diverticula”). The goals of surgery are to resect the diverticulum and to address the underlying motility disorder by performing a myotomy that extends from the proximal extent of the diverticulum across the lower esophageal sphincter. A partial fundoplication is added to prevent gastroesophageal reflux due to a lower esophageal sphincter rendered incompetent by myotomy. In the era of minimally invasive surgery, esophageal diverticula have been managed via laparoscopy and/or thoracoscopy. Given the epiphrenic location of most esophageal diverticula, laparoscopy is generally the minimally invasive procedure of choice (see Chapter 45, “Laparoscopic management of epiphrenic diverticula”). A myotomy of the lower esophageal sphincter and distal esophagus can be performed by this approach, a partial fundoplication added as an antireflux measure, and the diverticulum resected if it is situated sufficiently low within the mediastinum. Rightor left-sided thoracoscopy may be used as an adjunct to laparoscopy if the diverticulum cannot be reached through the hiatus. Only rarely should a thoracoscopic approach to diverticulectomy be performed as an independent procedure. Thoracoscopy hinders the performance of a myotomy that extends distally onto the stomach a sufficient length, increasing the risk of postoperative leak from the diverticulectomy site as well as the potential for persistent or recurrent symptoms. In addition, a fundoplication is not readily performed via a thoracoscopic approach.
As most epiphrenic diverticula are situated toward the right, right thoracoscopy typically allows optimal visualization. A limitation of the right-sided approach, however, is difficulty with exposure of the esophagogastric junction, hindering an adequate distal myotomy. A left-sided approach may facilitate the myotomy, but may provide inadequate visualization of many diverticula. In our experience, most epiphrenic diverticula are addressed first by laparoscopy, with a myotomy of the lower esophageal sphincter, a partial fundoplication, and a diverticulectomy, if feasible. Only if the diverticulum cannot be resected by this approach, and the patient continues to experience significant dysphagia or regurgitation, is subsequent thoracoscopy pursued.
OPERATIVE APPROACH
The operative principles are similar whether right or left thoracoscopy is being considered. The laterality of the diverticulum, as based upon preoperative barium esophagography, generally determines the side to be utilized. In most cases, a myotomy of the lower esophageal sphincter and partial fundoplication will have already been performed. Of course, the myotomy may need to be extended more proximally because of inadequate laparoscopic visualization of the thoracic esophagus.
Induction of anesthesia and positioning
The patient should be considered high risk for aspiration during induction of general anesthesia and intubation due to the presence of the diverticulum, the underlying esophageal motility disorder, and possible reflux that may have resulted from a prior myotomy. Rapid sequence induction with cricoid pressure and the patient in a semisitting position is generally utilized at our institution. The patient is then intubated with a double lumen endotracheal tube. Proper tube placement is confirmed bronchoscopically, and then the patient is rotated into the appropriate lateral decubitus position. Single lung ventilation is established to the contralateral lung, generally facilitating adequate thoracoscopic visualization of the esophagus and diverticulum. If exposure is inadequate, insufflation with carbon dioxide gas at a low pressure (5-8 mmHg) is feasible, though rarely necessary in our experience.
Trocar placement
The operation can usually be accomplished through three ports (see Figure 44.1 ). We prefer orienting the trocars so that the surgeon is standing toward the patient’s back and working in a posterior to anterior orientation rather than an inferior to superior one. With this orientation in mind, an attempt is made to triangulate the placement of the trocars within the confines of the hemithorax. Due to the scapula, the most superior trocar is generally a bit more posterior than what ideal triangulation would require. We utilize a 5 mm, 30-degree thoracoscope placed through a 5 mm trocar positioned at approximately the 8th intercostal space at the posterior axillary line. This trocar may be placed somewhat more superiorly for diverticula of the mid esophagus. The surgeon’s rightand left-hand operating ports are positioned at the mid to anterior axillary line (or slightly more posterior if the scapula tip is in the way), attempting to triangulate and being cognizant of the location of the ipsilateral hemidiaphragm. The deflated lung can generally be retracted with an instrument through the most superior port. Alternatively, the patient may be rotated more prone to aid in lung displacement away from the operative field. In addition, a stitch can be placed through the central tendon of the diaphragm and brought out through a small stab incision low on the lateral chest wall to retract the diaphragm inferiorly if necessary.
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