Resection of Epiphrenic Diverticulum

Epiphrenic diverticulum is an uncommon entity that most frequently occurs on the right side of the distal 10 cm of the esophagus. The pathogenesis of esopha-geal diverticula remains controversial [9]. The most common symptoms are dysphagia, heartburn, and regurgitation of undigested food particles. Surgery is indicated in symptomatic patients, and a myotomy at the time of the excision is recommended when abnormal motility is present. Longer instruments and reticulating wrists allow surgeons to extend the dissection deep into the thorax for more proximal diverticula and to operate in tight quarters, manipulating the esophagus without causing undue tension or torque on this structure. The robotic system clearly facilitates the dissection of the neck of the diverticulum when compared with conventional laparoscopic instruments. Once the diverticulum neck is identified and dissected free, the diverticulum is resected using an endoscopic linear stapler. Endoscopy is used to aid in identification of the diverticulum intraoperatively, and for inspection of the staple line following removal. When preoperative testing reveals a motility disorder, a myotomy with a Dor fundoplication is performed. The robotic-assisted approach via the abdomen has been used in six patients within our institution. As with myotomy for achalasia, we feel the robotic system markedly improves the accuracy which this can be performed thereby reducing the chance of mucosal perforation.

tion, the articulating hook makes possible a safe peri-esophageal dissection, preventing bleeding and trauma. Additionally, the robotics instruments are 7.5 cm longer than are standard laparoscopic instruments; therefore, it is possible a greater proximal mobilization beyond the level of the carina and a thoracoscopic approach is not necessary. With the esophagus fully mobilized, the stomach is then tubularized along the lesser curve, using several fires of a Linear Cutting Stapler (Ethicon, Cincinnati, Ohio). The esophagus is removed through the neck, and the anastomosis is performed. A total of 14 patients have undergone robotically assisted total esophagectomy for a diagnosis of high-grade dysplasia at our institution. In our series, the total operative time was 279 (175-360) min, including robotic setup time. Our last five cases averaged 210 min (range 175-210). The intraoperative average blood loss for the combined robotic and open cervical portions of the operations was 43 (10-60) ml. There were no intraoperative complications, and no patients developed laryngeal nerve injury postoperatively. The hospital stay averaged 8 (6-8) days. There have been no deaths, and our current average follow up is 264 (45-531) days. We believe that with minimal blood loss, short hospital and ICU stays, and lack of mortality, robotically assisted transhiatal esophagectomy has proven to a safe and effective operation. However, randomized controlled trials need to be conducted to inspect oncologic integrity if this operation is to be performed in patients with diagnoses other than high-grade dysplasia.

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