ZENKERS DIVERTICULUM

By Cheetanand Mahadeo For Dr M Rambarans Team

SURGICAL MANAGEMENT

Indications for surgery include:

Partial obstruction Dysphagia Choking sensation Coughing spells associated with aspiration

PRE-OP
Some sources advocate liquid diet for 2 days prior to operation Other sources require NPO for 8 hrs prior surgery with previous free diet One dose preop antibiotic as prophylaxis

ANAESTHESIA AND POSITIONING

GA is Preferred and endotracheal intubation Semi erect position is advocated by some authors Other authors only recommend a 20 degree head up position Shoulder pads and a head-ring is used so proper extension of the neck is achieved

ROSE POSITION NEEDED

INCISION
This is along the anterior border of the sternocleidomastoid muscle May extend from angle of mandible to sternal notch start incision and be prepared to extend if anatomic visualization is poor

LINE OF INCISION
Remember to spare the branches of the cervical cutaneous nerves if possible This crosses 2 3 cm below the angle of the mandible Centre of incision should be at the level of the thyroid cartilage

DETAILS OF THE PROCEDURE

The incision is made and continued through the subcutaneous tissues and the Platysma The investing fascia is opened and the sternocleidomastoid muscle is retracted laterally At the lower end of the incision, the omohyoid muscle crosses and this should be dissected and divided between hemostats and retracted

Sometimes the omohyoid muscle is thin and can be retracted out of the way so the carotid sheath is easily visualized Several structures are now visible

Investing pretracheal fascia and its contents, viz the thyroid gland The superior thyroid artery is seen and if space is needed, this can easily be ligated and the thyroid rotated medially

Thyroid Gland Omohyoid Cut

Diverticulum

Sternocleidomastoid Oesophagus and Neck of Sac with soft tissues

The soft tissues are now carefully dissected with a Peanut swab and only the sac is left connected Care must be taken to avoid the recurrent laryngeal nerve since it runs in the tracheo-oesophageal groove

Thyroid gland with intact capsule

Superior thyroid artery

As the dissection continues, the anaesthesia staff, should introduce an NG tube and this will be guided into the esophagus so as to assist with identifying the true neck of the sac The diverticulum must be carefull dissected off the lateral wall of the trachea and oesophagus so as to avoid tracheal, oesophageal and recurrent laryngeal injuries

Lateral wall of Oesophagus with myotomy

Thyroid Gland

Trachea and Recurrent Laryngeal Nerve under fascia

The sac is then opened and an oesophageal bougie approx 32 F is passed by the Anaesthesist The sac is opened slowly using the bougie as visual guide and held open with traction sutures

Stay sutures

Diverticulum

Oesophageal Bougie

An oesophageal myotomy is performed, starting at the inferior aspect of the sac and extending inferiorly for approx 4 cm, allowing the esophageal mucosa to bulge slightly The repair of the sac is then completed with 0000 sutures The dissected muscles are closed over the repair The omohyoid is also repaired and then the platysma after meticulous hemostasis Skin was closed with 000 Nylon sutures On table decision of no drain

POST OP CARE
NPO for 24 hours Morphine 5mg q 6h IVF DNS q 8h Nurse head up 2 pillows

Day 2 Start liquid diet Continue analgesia IVF at KVO

Regular diet Analgesia PRN Discharge with analgesia if tolerating diet well

THANK YOU

Friedrich Albert von Zenker 1825 -1898