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Herbella et al. Mini-invasive Surg 2020;4:82 I http://dx.doi.org/10.20517/2574-1225.2020.84 Page 3 of 7
[9]
era of minimally invasive surgery, thoracoscopy replaced thoracotomy as the preferred approach . The
thoracic approach gained popularity due to easy access to the diverticulum, especially in situations when its
ostium is more proximal into the esophagus. The thoracic route has some disadvantages as compared to the
abdominal approach that goes farther than the pulmonary morbidity and pain. The myotomy is associated
to worse outcomes when performed through the chest as compared to the abdominal route, especially
[11]
due to a high rate of gastroesophageal reflux . In addition, the development of staplers made easier the
[9]
resection of the diverticulum via laparoscopy . These advantages shifted the preference of modern authors
to the laparoscopic route . In addition, the laparoscopic approach allowed the performance of a partial
[8]
fundoplication after the myotomy to prevent pathologic reflux.
[8]
When outcomes are compared, disease recurrence is rare for both approaches and the results seem to
be similar for thoracoscopy and laparoscopy [8,12-14] . If diverticulectomy is considered important (due to
symptoms) after a laparoscopic myotomy and partial fundoplication, a thoracoscopic diverticulectomy is
safer.

[10]
Some technical tips may result in better outcomes . First, dissection of the upper border of the
diverticulum and of its neck is the most challenging aspect of the laparoscopic route. Even though the
diverticulum may appear to be located high in the esophagus, dissection of adhesions to surrounding
tissues and sufficient traction of the diverticulum and esophagus with a Penrose drain circling the
esophagogastric junction frequently allows dissection of high diverticula from below. It is important
to dissect the neck of the diverticulum free of the surrounding tissue and to clearly identify the muscle
layers. It must be remembered that ED is pseudodiverticulum, thus muscular fibers cannot be found at the
[15]
diverticulum itself. Some authors add an extra port for further assistance .
If the diverticulum will be resected, it is better performed on the opposite side of the diverticulum to avoid
interference with the resection and the muscle closure at that site. If the diverticulum will not be resected,
myotomy can be performed at the level of the neck of the diverticulum and extend onto the gastric wall
as in a Heller myotomy for achalasia. For the diverticulectomy, a 50-56-F bougie is placed inside the
esophagus to avoid narrowing of the lumen when the stapler is applied. Reticulating staplers should be
preferentially used to facilitate optimal positioning across the neck of the diverticulum, and the staple
height should be appropriate for the thickness of the tissue at the transection site. The muscle layers should
be approximated over the staple line with interrupted stitches. A partial fundoplication completes the
procedure [Figure 2].

Treatment of the dysmotility without diverticulectomy
An esophageal motor disorder is present in the majority, if not in all, patients with ED [6,10] . A
cardiomyotomy is always necessary when treating a symptomatic diverticulum, even if a dysmotility was
not detected by esophageal manometry because: (1) an esophageal dysmotility may not be detected by
[6]
conventional parameters and be missed by unexperienced physiologists ; (2) esophageal dysmotility such
as achalasia rather than the diverticulum per se may be responsible for most of the symptoms, such as
dysphagia and pulmonary symptoms [10,16] ; and (3) the addition of a myotomy decreases the chance of leak
[17]
due to a lower intraluminal pressure .
[14]
A recent systematic review and meta-analysis with 511 patients showed that the diverticulum was
[18]
left in situ in only 7% of the cases, mostly due to small size. Castrucci et al. also did not perform
a diverticulectomy in the presence of wide-necked diverticula without food retention in the pouch,
[19]
pulmonary aspiration, or mucosal lesions. D’Journo et al. advocated suspension of wide-necked
diverticula when there is no dependent portion of the diverticular sac and myotomy alone in the presence
of multiple small diverticula. Interestingly, outcomes were similar when the diverticula were resected or left
in place.