A Zenker’s diverticulum is a herniation of the esophagus through an area of dehiscence in the musculature posterior to the esophagus, known as a Killian dehiscence or the Killian’s triangle. The dehiscence occurs between the inferior pharyngeal constrictor and the cricopharyngeus muscle. While there have been historical attempts at medical treatment, including botox injection into the cricopharyngeus muscle, the standard of care at this time is surgical intervention.1 The previous gold standard was cricopharyngeus myotomy with open diverticulectomy. Given the open nature of the procedure, patients often encountered a prolonged hospital course necessitating prolonged enteral nutrition to allow for healing of the pharyngotomy wound.

A less invasive endoscopic approach was introduced by Mosher et al in 1917, and the technique continues to be developed to reduce morbidity for the patient.2 Dohlman and Mattsson reintroduced the endoscopic approach in 1960 with continued additions of electrocoagulation and lasers to assist with excision of the Zenker’s diverticulum.3 Recent reviews have shown that endoscopic techniques versus open-neck techniques lead to shorter operative times and shorter hospital stays.4 An endoscopic stapler technique will be described in this video, which has specifically been shown to result in shorter operative time, hospital stay, and time to resume oral feedings.1

The patient described experiencing several years of dysphagia to solid foods with intermittent regurgitation of foods, and a Zenker’s diverticulum was identified on modified barium swallow and barium esophagram.

While there are no specific absolute contraindications for this procedure, there are factors which may lead surgeons to choose a different approach. The size of the pouch helps determine the method for diverticulotomy. If the pouch is too small, an stapler approach may not be appropriate and laser or alternative excision methods may be considered.5 Zenker’s diverticula that are larger than 3.0cm should be considered for an open approach.6

Instrumentation
WEERDA Distending Operating Laryngoscope by Karl Storz (Karl Storz, Tuttlingen, Germany)
Lewy Fulcrum System (Karl Storz, Tuttlingen, Germany)
Endo Stitch Suturing Device (Medtronic, Minneapolis, MN)
Multifire Endo TA 30 Stapler (Medtronic, Minneapolis, MN)

Setup
The patient is laid supine and often turned 90 degrees counterclockwise. A shoulder roll may optimize neck extension and improve adequate exposure of the esophagus. A mouthguard is placed to protect the maxillary teeth. Once exposure of the postcricoid region is optimized, this view is isolated by suspending the patient using a Lewy Fulcrum System or other suspension device.

In addition to a routine head and neck examination, patients undergo fiberoptic transnasal laryngoscopy to examine the oropharynx and larynx to rule out any other anatomic etiologies for their dysphagia. The barium esophagram helps identify the size and location of the diverticulum, and may identify concurrent reflux.

Conversion to open diverticulotomy should be considered if adequate exposure of the Zenker’s diverticulum is not possible with transoral laryngoscopy or if the diverticulum is too large and extends beyond the access of endoscopic instruments.

The endoscopic stapler approach allows for shorter operative time, hospital stay, and reduced morbidity for the patient. The patient has no external, transcervical incision to heal. The potential disadvantage is inadequate exposure of the diverticulum, or recurrence of the diverticulum or symptoms.

Intraoperative complications include dental injury, bleeding, and esophageal perforation. Protecting the teeth with a mouth guard during laryngoscopy will help prevent dental injury.

Early complications defined as within the first 7 days include postoperative subcutaneous emphysema, infection, pneumonia.6 Postoperative ambulation and incentive spirometry can help prevent pulmonary complications secondary to surgical intervention.

Late complications defined as more than 7 days include postoperative dysphagia reflux symptoms. Patients with hiatal hernia and preoperative gastroesophageal reflux have been shown to have higher postoperative morbidity, and preoperative management of reflux may help with postoperative regurgitation and reflux symptoms.7

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1. Smith SR, Genden EM, Urken ML. Endoscopic Stapling Technique for the Treatment of Zenker Diverticulum vs Standard Open-Neck Technique: A Direct Comparison and Charge Analysis. Arch Otolaryngol Neck Surg. 2002;128(2):141. doi:10.1001/archotol.128.2.141
2. Macmillan AS. Pouches of the Pharynx and Esophagus. J Am Med Assoc. 1932;98(12):964. doi:10.1001/jama.1932.02730380032009
3. Dohlman G, Mattsson O. The endoscopic operation for hypopharyngeal diverticula: a roentgencinematographic study. AMA Arch Otolaryngol. 1960;71:744-752.
4. Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenker’s diverticulum). Eur Arch Otorhinolaryngol. 2010;267(4):587-592. doi:10.1007/s00405-009-1079-4
5. Adams J, Sheppard B, Andersen P, et al. Zenker’s diverticulostomy with cricopharyngeal myotomy: The endoscopic approach. Surg Endosc. 2001;15(1):34-37. doi:10.1007/s004640000323
6. Howell RJ, Giliberto JP, Harmon J, et al. Open Versus Endoscopic Surgery of Zenker’s Diverticula: A Systematic Review and Meta-analysis. Dysphagia. 2019;34(6):930-938. doi:10.1007/s00455-019-09994-9
7. Nitschke P, Kemper M, König P, et al. Interdisciplinary Comparison of Endoscopic Laser-Assisted Diverticulotomy vs. Transcervical Myotomy as a Treatment for Zenker’s Diverticulum. J Gastrointest Surg. September 2019. doi:10.1007/s11605-019-04381-z