PMC3016038_01
(A) Preoperative contrast study showing a large epiphrenic diverticulum (arrow) and small hiatal hernia. (B) Preoperative spiral computed tomgraphic scan demonstrating an esophageal diverticulum with a large neck.
jsls-12-1-104-g01.jpg
PMC3016038_01_jsls-12-1-104-g01.jpg
F1
The initial diagnosis was performed by barium esophagram, which showed an epiphrenic diverticulum located at the right side of the esophagus and the presence of a concomitant hiatal hernia (Figure 1A). The maximum diameter of the diverticulum pouch was 10 cm with a neck size of 7 cm (Figure 1B).
Preoperative flexible endoscopic view of the diverticulum.
jsls-12-1-104-g02.jpg
PMC3016038_01_jsls-12-1-104-g02.jpg
F2
Flexible endoscopy was performed to exclude any diverticular ulceration or neoplastic strictures; the endoscopist identified the neck of the diverticulum at 7 cm to 10 cm from the esophagogastric junction and confirmed the x-ray evidence of hiatal hernia without severe esophagitis (Figure 2).
(A) Operative team position; (B) trocar placement.
jsls-12-1-104-g03.jpg
PMC3016038_01_jsls-12-1-104-g03.jpg
F3
The patient was positioned in an anti-Trendelenburg (30-degree) supine position with legs spread; the surgeon stood between the patient's legs (Figure 3A). Two 10/12-mm trocars and three 5-mm trocars were placed (Figure 3B). The stapler was introduced through the 12-mm trocar placed at the left subcostal margin (trocar 2 - Figure 3B) and fired with the device parallel to the esophagus (Figure 4A). The resected diverticulum was removed in a retrieval bag.
Intraoperative figures (A) diverticulectomy using endoscopic linear stapler; (B) Dor's fundoplication.
jsls-12-1-104-g04.jpg
PMC3016038_01_jsls-12-1-104-g04.jpg
F4
The stapler was introduced through the 12-mm trocar placed at the left subcostal margin (trocar 2 - Figure 3B) and fired with the device parallel to the esophagus (Figure 4A). The resected diverticulum was removed in a retrieval bag. The procedure was completed with a standard esophageal myotomy (7 cm to 8 cm on the esophagus along the opposite side of the resected diverticulum plus 3 cm on the stomach), hiatoplasty with 2 nonabsorbable interrupted stitches (Prolene, Ethicon, Inc., Somerville, NJ, USA), and a Dor's fundoplication (Figure 4B).