Thoracoscopic resection of thoracic esophageal diverticula

The description of the thoracoscopic resection of thoracic esophageal diverticula covers all aspects of the surgical procedure used for the management of thoracic esophageal diverticula. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of diverticulum, dissection of diverticulum, dividing the neck of the diverticulum. Consequently, this operating technique is well standardized for the management of this condition.

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Thoracoscopic   resection   of   thoracic   esophageal   diverticula

Authors
D Gossot, D Mutter
Abstract
The description of the thoracoscopic resection of thoracic esophageal diverticula covers all aspects of the surgical procedure used for the management of thoracic esophageal diverticula.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of diverticulum, dissection of diverticulum, dividing the neck of the diverticulum.
Consequently, this operating technique is well standardized for the management of this condition.
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Publication
2001-04
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E-publication
WeBSurg.com, Apr 2001;1(04).
URL: http://www.websurg.com/doi-ot02en205.htm

Thoracoscopic   resection   of   thoracic   esophageal   diverticula

1. Introduction
Diverticula of the esophagus are rare. Traction diverticula, which used to occur in certain chronic mediastinal forms of tuberculosis and infections, have now become rare.
Currently, surgical intervention is only considered in cases of pulsion diverticula. These diverticula are often associated with an esophageal motility disorder that must be treated at the same time or secondarily for a complete recovery.
2. Anatomy
• Main relationships
• Location
The thoracic esophagus is situated in the posterior mediastinum, below the mediastinal pleura. Its upper three fourths extends inferiorly in the right side of the thorax. After crossing in front of the aorta, it enters the left hemithorax. The upper two thirds of the esophagus should therefore be approached from the right and the lower one third from the left.
• Anterior surface
The esophagus is successively in close contact with the following anatomical structures:
- the membranous wall of the trachea and the origin of the left main bronchus;
- the right pulmonary artery;
- the pericardium.
• Posterior surface
The esophagus is successively in contact with the following anatomical structures:
- the rachis, from which it gradually separates starting from the fourth dorsal vertebra (D4);
- the thoracic aorta;
- the azygos vein;
- the thoracic duct, in the angle between the esophagus and the aorta.
• Right side
The esophagus is traversed by the arch of the azygos vein.
The rami of the right vagus nerve extend along its right side.
• Left side
It is mainly in contact with the aorta, the inferior pulmonary vein and the left vagus nerve.
• Vasculature
All of the esophageal arteries are branches of the thoracic aorta, except in the superior aspect where the esophagus is supplied by branches of the inferior thyroid artery, and in the inferior aspect where it receives branches of the left gastroomental artery and of the phrenic arteries.
• Difficulties
Because of the posterior mediastinal location of the esophagus, adequate retraction of the lungs is mandatory for exposure of the operative field, especially when a right thoracotomy is performed. Selective intubation is therefore indispensable due to the fact that manual retraction is not possible in thoracoscopy.
The lesions situated on the left edge of the upper two thirds of the esophagus must be approached only from the right. Consequently, exposure of the esophagus can only be achieved by rotating it. This rotation must be minimal, however, to avoid any risk of denervation.
• Danger areas
• Principle
Surgery for benign pathologies is performed in direct contact with the esophagus. Certain structures that are normally exposed in cancer surgery (thoracic duct, membranous wall of the trachea) are not well visualized in this surgical technique.
• On the right
The arch of the azygos vein is intimately related to the middle and upper thirds of the esophagus and can be easily injured during its dissection. It is imperative to check it before dissection, because any damage to it would be difficult to control by thoracoscopy.
The rami of the vagus nerve must, if at all possible, be preserved.
• On the left
Access to the esophagus may require freeing of the pulmonary ligament. Care must be taken to remain at a distance avoid injuring the left inferior pulmonary vein at its superior pole.
The left vagus nerve must be preserved.
3. Indications
Indications
Esophageal diverticula are rare.
Traction diverticula, found in certain chronic mediastinal forms of tuberculosis and infections, are rare.

The indications for open chest surgery for the repair of esophageal diverticulum are becoming more and more scarce. The operation performed by thoracoscopy is identical to that of thoracotomy.
An open chest approach is indicated in the following situations:
- contraindication or impossibility to perform selective intubation;
- pulmonary emphysema or chronic obstructive pulmonary disease (COPD) with an increased risk for an incomplete pulmonary collapse that would hinder exposure of the posterior mediastinum;
- previous thoracotomy;
- traction diverticulum, often associated with severe peridiverticular inflammation.

Relative contraindication
At the present time, a surgical procedure is considered only for pulsion diverticula, usually associated with an esophageal motility disorder (Altorki et al., 1993). An operative repair is considered when the diverticulum is symptomatic (dysphagia, episodes of food blockage, inhalation pneumopathy).

4. Preop period
Preoperative studies include:
- gastroesophageal endoscopy;
- barium esophagram, including side views and three-fourth views for optimal evaluation of the site of the diverticulum, and the approach to be used;
- esophageal manometry;
- 24-hour pH-monitoring if associated gastroesophageal reflux is suspected.
5. Motility disorders
When the preoperative manometry reveals increased pressure of the lower esophageal sphincter and an associated motility disorder (most frequent case in pulsion diverticula), it is preferable to also perform a myotomy. However, some authors do not perform a myotomy routinely (Altorki et al.,1993; Rosati et al., 1994).

The myotomy can be done:
- by right thoracoscopy during the same operation, if enough gas can be expelled from the stomach into the esophagus to perform the myotomy at a distance from the staple line, and if the gastroesophageal junction can be reached (this is not always possible);
- by left thoracoscopy, during a subsequent operative time, which gives an easier approach to the gastroesophageal junction and ensures a proper distance from the staple line;
- by laparoscopy, during a subsequent operative time. This approach allows to combine an antireflux procedure.
6. Operating room set-up
• Patient
- general anesthesia;
- right lung separated by a selective Carlens-type intubation catheter. Its correct position is confirmed by fibroscopy;
- if a gastroesophageal tube is used, it must not be inserted until the esophagus is exposed, under the surgeon’s visual control, to avoid any risk of perforating the diverticulum;
- patient positioned in left lateral decubitus, tilted slightly forward to expose the posterior mediastinum;
- right arm raised in a splint to allow access to the armpit for the placement of supplementary trocars if needed. It should be pulled back far enough (taking care not to stretch the brachial plexus) so as not to hinder the handling of the instruments that are being directed towards the diaphragm.
For diverticula situated in the lower third of the thorax, it is preferable to leave the arm hanging, to facilitate the handling of the videoscope and instruments (Altorki et al., 1993).
• Team
1. The surgeon stands behind the patient.
2. The assistant stands opposite the surgeon.
Both are able to view separate video monitors
• Equipment
1. Operating table
2. Anesthetic equipment
3. Thoracoscopic unit
4. Monitors
5. Small instrument table
6. Large instrument table
7. Trocar placement
• Principles
There is no one standard way of positioning the trocars, as it depends on the location of the diverticulum. The trocar positions may vary by 1 to 2 intercostal spaces, depending on how high the diverticulum is situated.
In the case of a diverticulum situated at the junction of the middle third and lower third of the esophagus, the trocars are placed as follows.
• Optical
A: The optical trocar is inserted on the mid-axillary line in the sixth intercostal space.
• Operating
D: A 12 mm trocar is inserted on the anterior axillary line, in the seventh intercostal space, for the dissecting instruments and stapler.
• Retractors
B: A 10 mm trocar is inserted on the anterior axillary line, very anteriorly, in the fourth or fifth intercostal space, for the retractor device.
Once the posterior mediastinum has been exposed, the 2 other trocars are introduced.
C: A 10 mm trocar is inserted on the posterior axillary line, in the seventh intercostal space, for a 10 mm grasper.
8. Instruments
• Principles
The instrumentation kit includes standard straight and curved thoracoscopic instruments. The curved instruments are used only in the case of unsuspected pleural adhesions.
As for all video-assisted thoracic surgery, a conventional thoracic surgery instrumentation kit is available in the operating room.
• Optical devices
One 10 mm direct view (0°) scope is sufficient.

Visual axis
Visual field
• Operating devices
- 5 mm Metzenbaum type scissors
- peanut swab
- dissector
- endoscopic stapler with adjustable head
A bougie may be used to assist in guiding during stapling.
• Retractors
- 5 mm grasper
- 10 mm grasper
- fan-type lung retractor
9. Major principles
The procedure aims to relieve patients suffering from dysphagia by performing the 2 following surgical acts:
- remove the diverticulum in which food accumulates. The resection should be done at the
level of the esophagus to give it back its normal caliber, and without any traction to avoid any
dehiscence along the line of the staples;
- if necessary, treat the associated motor disorder by performing a myotomy, either during the same operative phase or subsequently, depending on technical difficulties.

The diverticulum is often situated in the middle third of the esophagus or at the junction of its middle third and lower third. The only possible approach in these cases is a right thoracic approach.
For epiphrenic diverticula, a left thoracic approach is preferable. However, certain authors recommend a laparoscopic approach (Chami et al., 1999; Rosati et al., 1994). The advantage of the laparoscopic approach is the possibility it offers to perform a satisfactory myotomy and to perform a fundoplication if needed.
In the following description, a pulsion diverticulum of the junction of the middle third-lower third of the esophagus will be used as an example.
10. Exposure/diverticulum
• Right anterior diverticulum
When the diverticulum lies on the right anterior edge of the esophagus, it is immediately visible.

• Left anterior diverticulum
A diverticulum can be situated on the left anterior side of the esophagus and not be visible. It is therefore necessary to open the mediastinal pleura in the area where the diverticulum is presumed to be. This is done sharply with scissors. The diverticulum can then be exposed by exerting cephalad and caudal traction on the esophagus.
11. Dissection/diverticulum
• Grasping the diverticulum
The tip of the diverticulum is grasped with a 5 mm grasper inserted through the posterior trocar.
Once the fibrous attachments have been divided and retracted, it is generally easy to find a good dissection plane while exerting strong cephalad traction on the tip of the diverticulum.
• Dissection
Adhesions are retracted to free the neck of the diverticulum, with Metzenbaum-type scissors, a peanut swab or a combination of both.

• Danger
If the diverticulum is situated in the thoracic or abdominal segments, it may be entwined in the vagus nerve branches. To preserve these nerve fibers as much as possible, particular caution must be taken during dissection to carefully untwine them from the diverticulum.
12. Dividing/neck
• Division
An endoscopic stapler is introduced into the 12 mm anterior trocar. Staplers with adjustable heads allow for a very precise positioning of the line of staples in line with the esophagus. While applying staples to the neck of the diverticulum, it is important to have a proper view of the esophagus to avoid causing stenosis. When in doubt, a large caliber bougie can be helpful.
• Control
After stapling and dividing the neck, the region is irrigated with serum and air is insufflated into the esophagus by the anesthesiologist to make sure that there are no leaks along the line of staples.
With adjustable staplers, traction need not be exerted on the diverticulum or esophagus to correctly position the staples. The risk of splitting is therefore very low.
It is not useful to cover the line of staples.
• Danger
Danger: intraoperative complication
The esophageal mucosa may be injured during dissection of the diverticulum. If the injury is located at a distance from the neck, it may be left alone. If it is near the neck, the surgeon must make sure that it will be taken in the line of staples. In case of doubt, it is preferable to convert to thoracotomy.

13. End/procedure
The nasogastric tube is removed.
A 24 French thoracic drain is placed in the posterior mediastinum, making sure that its tip does not come into contact with staples.
The lung is reinflated and the trocar sites are closed by the usual technique.
14. Postop period
Care
A postoperative water-soluble contrast swallow is done on the day after the operation.
After verifying that there are no fistulas, the drain may be removed on POD1 and food intake resumed.
The patient may leave hospital on POD3.

Complications
An esophageal fistula is detected on the postoperative contrast swallow, which is mandatory before resuming food intake.
It results from an incorrect positioning of the line of staples and/or excessive traction on the esophagus while applying of the stapler. The use of adjustable stapler heads should prevent this serious complication from occurring.

If pleural effusion occurs, it is generally minimal, limited to a filling of the pleural cul-de-sac. No treatment is required other than prescribed respiratory exercises.
15. Reference
D Mutter, MD, PhD
Hôpitaux Universitaires de Strasbourg,
Strasbourg, France
Altorki NK, Sunagawa M, Skinner DB. Thoracic esophageal diverticula. Why is operation necessary? J
Thorac Cardiovasc Surg 1993;105:260-4.
Chami Z, Fabre JM, Navarro F, Domergue J. Abdominal laparoscopic approach for thoracic epiphrenic
diverticulum. Surg Endosc 1999;13:164-5.
Gossot D. Access modalities for thoracoscopic surgery. In: Toouli J, Gossot D, Hunter JG, editors.
Endosurgery. New York: Churchill Livingstone; 1996. p. 743-51.
Rosati R, Bona S, Fumagalli U, Bonavina L, Peracchia A. Considerations on minimally invasive approach
to epiphrenic oesophageal diverticula. Surg Endosc 1994;8:962.