Operations for esophageal diverticula

Surgical approaches

The choice of surgical approach is determined by the precise localization of the pathological formation in the thoracic cavity:

• Bifurcation diverticula (Th3–Th5 level): Right-sided lateral thoracotomy is considered the optimal approach. The incision is made in the 5th or 6th intercostal space. Important topographical and anatomical feature: for adequate access to the esophagus at this level, the surgeon may need to ligate and subsequently transect the arch of the azygos vein.
• Supradiaphragmatic (epiphrenic) diverticula: The surgery is performed via thoracotomy in the 7th intercostal space. The approach can be either right-sided or left-sided, depending on the direction of the esophageal wall protrusion.

Diverticulectomy technique

Removal of the diverticulum requires a strict sequence of steps to prevent mediastinal infection and fistula formation:

1. Access to the organ: After opening the pleural cavity, the lung is gently retracted anteriorly.
2. Revision: The localization of the protrusion is verified via visual inspection, palpation, and air insufflation through a pre-inserted esophageal tube.
3. Mobilization: The diverticulum is dissected from the surrounding mediastinal tissues down to its neck. Extreme caution is required at this stage due to frequent adhesions between the diverticular wall and the adjacent bronchus.
4. Management of the neck: A special clamp is applied to the base (neck) of the diverticulum. The wall is sutured with a continuous mattress suture.
5. Transection: The diverticulum is excised, after which the clamp is removed.
6. Suturing: A continuous suture is placed once again through all layers of the esophageal wall and securely tied.
7. Peritonization: The muscular layer of the esophagus is carefully approximated and sutured over the placed suture.

Completion of surgery and Petrovsky plasty

The reconstructive phase of the operation is completed by placing fine interrupted sutures. If the muscular layer of the esophagus is poorly developed and cannot ensure reliable coverage of the defect, Petrovsky plasty is employed. The essence of the method lies in reinforcing the weak area of the wall with a specially tailored pedicled diaphragmatic flap.

The incised area of the mediastinal pleura is meticulously sutured with separate interrupted sutures. The chest wall is closed tightly, with a mandatory drainage tube left in the pleural cavity to monitor exudation and prevent fluid accumulation.

Operations for benign tumors and cysts

The main principle of surgical treatment for benign esophageal neoplasms is enucleation of the tumor without opening the organ lumen. Access is achieved through a right-sided or left-sided lateral thoracotomy in the intercostal space corresponding to the level of the lesion.

Stages of tumor removal:

1. Incising the mediastinal pleura directly over the formation.
2. Partial mobilization of the esophageal wall in the tumor localization zone.
3. Suturing the tumor tissue with figure-of-eight stitches to form a convenient traction suture ("holder").
4. Isolation of the formation: the surgeon pulls on the traction suture and bluntly (using a tupfer) or with scissors enucleates the tumor. It is critically important not to damage the esophageal mucosa during this process.
5. Suturing the muscular layer defect with fine interrupted sutures after complete removal of the lesion.
6. If necessary (if the muscle layer is frail or the tumor was located low), the wall is additionally reinforced by suturing the mediastinal pleura or a pedicled diaphragmatic flap to it.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographical anatomy of the azygos vein arch and the technique of its ligation during right-sided thoracotomy
• Features of forming a continuous mattress suture on the esophageal wall
• Technique of harvesting a pedicled diaphragmatic flap according to Petrovsky
• Preoperative diagnostics and esophageal probing for intraoperative visualization of the diverticulum
• Prevention and treatment of mediastinitis in case of accidental mucosal entry during enucleation

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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