Zenker's Diverticulum Repair
What the Examiner Expects
Repair of a posterior pharyngoesophageal (Zenker's) diverticulum, a pulsion diverticulum arising through Killian's triangle between the oblique fibers of the inferior pharyngeal constrictor and the transverse fibers of the cricopharyngeus. The examiner expects you to recognize the classic presentation (progressive dysphagia, regurgitation of undigested food, halitosis, aspiration) and confirm with a barium swallow (NOT endoscopy first, due to perforation risk). The key operative principle is that cricopharyngeal myotomy is the essential step — the diverticulum forms due to outflow obstruction. The diverticulum can be excised (diverticulectomy), suspended (diverticulopexy), or divided endoscopically.
Key Examiner Focus Points
- Pulsion diverticulum at Killian's triangle (between cricopharyngeus and inferior constrictor)
- Cricopharyngeal myotomy is the essential component of the repair
- Diverticulectomy or diverticulopexy is secondary to the myotomy
- Endoscopic stapled diverticulotomy is a minimally invasive alternative
- Recurrent laryngeal nerve at risk during open transcervical approach
Common Curveballs
The diverticulum is small (< 2 cm)
Cricopharyngeal myotomy alone is sufficient. Diverticulectomy is unnecessary for small diverticula — the myotomy treats the underlying cause of outflow obstruction.
You suspect perforation during endoscopic approach
Convert to an open transcervical approach. Repair the perforation primarily, perform the cricopharyngeal myotomy, drain the neck, keep NPO, and start IV antibiotics.
Patient develops hoarseness postoperatively
Recurrent laryngeal nerve injury. Obtain laryngoscopy to evaluate vocal cord function. If unilateral, usually managed expectantly. This is preventable with careful dissection during the transcervical approach.
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