Zenker Diverticulum Repair

Transcervical Cricopharyngeal Myotomy And Diverticulectomy or Suspension

1. Incise left neck along anterior sternocleidomastoid.
2. Retract muscle and sheath laterally.
3. Divide omohyoid, sternothyroid and sternohyoid to expose cervical esophagus.
4. Expose diverticulum.
- located posterior to the cricoid, sheathed in fibrous tissues that must be divided.
5. Longitudinal myotomy on posterolateral aspect of the cervical oesophagus.
- from just inferior to the base of the diverticulum, to the thoracic inlet
- typically the muscle at the bottom of the divertic is thickened and fibrotic.
- once released will see the divertic clearly.
- also divide the lower fibers of inferior pharyngeal constrictor superiorly form base of divertic, for 1-2 cm.
- and bluntly dissect these to widely splay open the mucosa, identifying any residual muscle fibres.
6. Suspend or excise the divertic.
- if <2cm suspend by tacking the tip with 3-0 prolene to precervical fascia as high as necessary to upend the pouch.
 - larger pouches should be divided with a TA stapler with a 52Fr bougie in the esophagus.
- check for leaks using a nasogastric tube and insufflating air with incision filled with saline.
7. Perfect haemostasis, as can bleed when coughing or straining on waking.
- small closed suction drain and approximate platysma and skin

Transoral endoscopic stapled

Attractive as no neck incision
But only suitable if large pouch (>3cm), patient can open mouth widely, extend neck, and no malignancy in the pouch.
- warn of chipped teeth from the rigid scope.

See Cameron for details; not covered.