Laproendoscopic single site oesophageal diverticulectomy.

Epiphrenic divericula are uncommon disorders of the lower oesophagus, which are symptomatic in only 15-20% of cases. The optimum treatment modality for such cases remains an oesophageal diverticulectomy with long myotomy with or without an antireflux operation. Recently, this is increasingly being done through the laparoscopic approach. Here we describe the first reported case of oesophageal diverticulectomy through the laparoendoscopic single site approach. A 57-year-old man presented to us with 6 months history of dysphagia and regurgitation. Patient was investigated with upper gastrointestinal (UGI) endoscopy, barium swallow, CECT chest and abdomen, oesophageal manometry and 24 hour pH study. He was diagnosed to have lower oesophageal diverticulum with mildly elevated pressure readings in manometric studies with normal peristalsis. Based on his symptoms, he was taken up for surgery. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy was done through laparoendoscopic single site technique. The procedure lasted 160 min. There was no intraoperative complication. Gastrograffin study was done on postoperative day 2 following which he was started on liquids. He made an uneventful recovery and was discharged on fourth day. He remained asymptomatic on follow up. Oesophageal diverticulectomy is possible through laparoendoscopic single site approach if necessary expertise is available.

INTRODUCTION

Epiphrenic diverticula are rare disorders of the oesophagus, which are symptomatic in only 15–20% of cases.[1] They are usually found in the lower third of the oesophagus in middle-aged or elderly persons. There is usually an associated motility disorder of the oesophagus (43–100%). Standard treatment of the epiphrenic diverticulum includes diverticulectomy, oesophageal myotomy with or without antireflux operation[2] with left thoracotomy being the recommended approach. The high morbidity associated with thoracotomy means that only persons with disabling symptoms or complications should be treated.[3] Asymptomatic patients should be left untreated, because few asymptomatic patients will present symptoms at follow-up.

Recent advances in minimal access surgery have led to the application of this technique for the management of epiphrenic diverticula.[4] Many recent publications have shown that laparoscopic transhiatal oesophageal diverticulectomy is safe and efficacious.[5] It dramatically reduces the morbidity of the procedure and is associated with less pulmonary complications, minimal pain and shorter hospital of stay. We have previously published our own institute's experience in minimally invasive management of lower oesophageal diverticula.[6] Now with increasing emphasis on patient comfort and cosmesis, surgeons have decreased the number of incisions used in laparoscopic surgery and thus the era of single incision laparoscopy has begun. Many procedures such as cholecystectomy, appendicectomy, colectomy and others have been done successfully using single incision laparoscopy and have proven to be safe and advantageous compared with conventional laparoscopy.[7] We report the first case of laparoendoscopic single site transhiatal oesophageal diverticulectomy with myotomy.

CASE REPORT

The patient was a 57-year-old man with 6 months history of dysphagia and regurgitation. upper gastrointestinal (UGI) endoscopy was done which showed large wide mouthed diverticulum in lower oesophagus around 36 cm from the incisors. The mucosa within the lumen of diverticulum was normal and there was no other lesion in oesophagus, stomach or duodenum. Subsequently, barium swallow and Contrast Enhanced Computerised Tomography chest and abdomen were done which confirmed the diagnosis of epiphrenic diverticulum measuring 5 cm in maximum diameter arising from posterolateral wall of oesophagus around 4 cm above the Gastro Esophageal junction. Oesophageal manometry showed diffuse increase in pressure tracings with hypertensive Lower Esophageal Sphincter but normal peristalsis and LES relaxation with swallow. Twenty-four hour pH study did not reveal presence of preoperative reflux. The patient was taken up for surgery based on the severity of symptoms and objective findings. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy through single incision was planned.

Patient was kept on liquid diet 1 day prior to surgery and was fasting overnight. Operation was performed under general anaesthesia with patient supine and legs apart with steep reverse trendelenberg tilt. A Ryle's tube was placed before induction. The surgeon stood between the legs of the patient with a camera assistant to the left and scrub nurse to the right of the surgeon. A 4 cm transverse skin incision was made within the umblicus and deepened upto the anterior rectus sheath. Pneumoperitoneum was created using Veress needle and a 10 mm trocar for laparoscope was placed in the centre of the incision. Two 5 mm trocars were placed on either side for the working instruments creating a mini triangulation effect [Figure 1]. Initial peritoneoscopy was done and then left lobe of liver was retracted by placing heavy double armed silk onstraight needle through a corrugated plastic drain and brought out through the liver parenchyma and the anterior abdominal wall [Figure 2]. This suture was kept on traction with help of small artery forceps. The dissection started with opening up of the avascular gastrohepatic omentum and division of phrenoesophageal membrane and gastrophrenic attachments of the fundus. The right crus of diaphragm was identified and dissected and retroesophageal space created. An umbilical tape was placed and tied around the GE junction after this dissection and brought out through the right trocar for traction during circumferential mobilisation of the oesophagus. The hiatus was opened anteriorly and lower end of mediastinal oesophagus was dissected. The diverticulum was visualised and peridiverticular adhesions were released. The left mediastinal pleura was carefully stripped off the diverticulum. The diverticulum was freed upto its neck, 5 mm right lateral trocar was replaced by a 12 mm trocar and the diverticulum was then divided with two firings of 60 mm linear stapler with a blue cartridge [Figure 3]. Intra operative endoscopy confirmed mucosal integrity and adequacy of lumen of the oesophagus. An anterior oesophageal myotomy was done starting from 6 cm above GE junction and extending 2 cm into the stomach. The mucosal integrity was once again confirmed with endoscopy and air leak test was done. Finally, the specimen was placed in a plastic bag and extracted and drain was placed. Fascial incisions were closed with No 1 loop nylon and skin with subcuticular absorbable suture [Figure 4].

Figure 1

Port placement

Figure 2

Retraction of liver with corrugated plastic drain

Figure 3

Firing GI stapler across diverticulum

Figure 4

Postoperative photograph

DISCUSSION

Epiphrenic diverticula of oesophagus are considered to be pulsion diverticula caused by increased intra oesophageal pressure secondary to motility disorder.[1] Functional obstruction at the lower end of oesophagus is thought to be the major cause of symptoms such as dysphagia, heartburn and regurgitation. Since majority of the diverticula are asymptomatic or producing mild symptoms, conservative approach is advocated. Surgery is reserved for patients with incapacitating symptoms or life threatening complications.

The surgical therapy for oesophageal diverticulae has evolved tremendously. The traditional accepted surgery used to be an oesophageal diverticulectomy with long myotomy with or without an antireflux procedure performed through a left thoracotomy.[2] This removed the diverticula, took care of the underlying motility disorder and post operative reflux. But this procedure was associated with significant morbidity and mortality which was not acceptable for a benign disorder.[3] Minimal invasive surgery led to use of thoracoscopy for excision of oesophageal diverticula but it was complicated by technical difficulty and inability to perform an adequate distal myotomy.[8] Laparoscopy has been established as the gold standard for a variety of oesophageal disorders like achalasia, hiatal hernia and severe Gastro Esophageal Reflux Disease. Rosati first reported laparoscopic transhiatal excision of epiphrenic diverticula in 1998. The transhiatal laparoscopic approach is ideally suited for management of lower oesophageal diverticula as it avoids the morbidity of thoracic approach. It affords excellent view of the lower mediastinum and allows comfortable alignment of the laparoscopic instruments along the hiatus. The performance of oesophageal diverticulectomy using linear stapler is easier by this approach and reduces the chance of stricture formation. It also is well suited for performance of long oesophageal myotomy and an abdominal antireflux procedure. The technical difficulty encountered is during dissection of diverticulum from the adherent pleura and instrument triangulation in a confined space.

An extrapolation of this technique is performance of laparoscopic transhiatal diveticulectomy through the single incision approach. Single incision laparoscopy has already emerged as a strong contender for Natural Orifice Translumenal Endoscopic Surgery in terms of providing virtually scarless surgery. It is more comfortable for experienced laparoscopic surgeons since it makes use of existing laparoscopic instruments and technology with few modifications in the operating technique. Though many procedures ranging from basic to advanced have been successfully done using single incision laparoscopy, none so far have described the application of this technique for transhiatal oesophageal diverticulectomy.

The advantages are the superior cosmesis, elimination of complications related to multiport technique such as port site hernia, bleeding and nerve injury.[9] Since the hiatus is nearly a midline structure, multiple ports placed through a transumblical incision allow direct access for dissection and manipulation. Liver retraction is done using many innovative techniques such as corrugated drain through which a double armed silk suture onstraight needle has been passed and brought out through liver substance and the anterior abdominal wall. Instrument triangulation is achieved by raising skin flaps and placing ports at over a wider area. Making use of long instruments keeps the instrument handles in different planes and avoids clashes outside the abdomen. We also make use of the endoeye scope (Olympus, America) which has integrated light and camera cable with chip on stick technology thus requiring less space and making it easier for the camera operator to manipulate the instrument.

Difficulties encountered during proximal dissection of the diverticulum and separation from the adherent pleura. Patience and meticulous technique is required for this phase of dissection to avoid pleural injury. Since diverticulectomy alone has been associated with increased rate of recurrences and suture line leaks, a long myotomy is performed anteriorly extending proximally from above the diverticular neck to distally 2 cm below the GE junction. An antireflux procedure was deferred in this particular case due to absence of symptoms of heartburn and objective evidence of preoperative reflux. Also the oesophagus had normal peristaltic contractions and an adequate Lower Esophageal Shincter relaxation with swallow so a fundoplication was deemed unnecessary. The patient remained symptom free during short-term follow-up of 6 months.

CONCLUSION

LESS transhiatal oesophageal divericulectomy is possible in hands of expert laparoscopic surgeons without compromising the safety of the procedure.