Laproendoscopic single site oesophageal diverticulectomy
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.\nPatient 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 []. Initial peritoneoscopy was done and then left lobe of liver was retracted by placing heavy double armed silk onstraight needle through a corrugated plastic drain and brought out through the liver parenchyma and the anterior abdominal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 []. 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 []. 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 [].