The laparoscopic transabdominal approach for resection of the large epiphrenic esophageal diverticulum

Background: Epiphrenic (supradiaphragmatic) esophageal diverticula are epithelial-lined mucosal pouches that protrude through the esophageal wall. Almost all of these pulsion diverticula are acquired and appear within the last 10 centimeters of the distal esophagus. Among others, the main cause of the occurrence of these gigantic diverticula is achalasia. We present a 54-year-old male patient with symptoms of large epiphrenic diverticulum, and achalasia Eckardt score 7. Presentation of case: The results of the gastrografin swallow test, computed tomography, and esophageal manometry showed a large epiphrenic diverticulum, and therefore surgical treatment was indicated. We performed laparoscopic transhiatal diverticulectomy, Heller myotomy, hiatoplasty, and Dor fundoplication. The overall operation time was 180 minutes. While performing Heller myotomy, an iatrogenic lesion of esophageal mucosa appeared within 2 centimeters of the lower esophageal sphincter. The perforation was immediately closed with a single suture. After this, a Dor fundoplication was created. On the fifth postoperative day, a gastrografin swallow test was performed with no evidence of a suture-line leakage. On the sixth postoperative day, the patient was discharged home in good general condition. Discussion and conclusion: Resection of esophageal diverticula by a transabdominal laparoscopic approach is a feasible method that, in the case of intraoperational incidents such as lesions of the esophageal wall, enables prompt and excellent visualisation of the lesion site. Furthermore, primary suturing of iatrogenic perforation of the distal esophagus is a feasible technique for resolving these kinds of surgical complications, also taking into account the fact that a Dor fundoplication is then created over the lesion site.