DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Zenker’s diverticulum.
POSTOPERATIVE DIAGNOSIS:
Zenker’s diverticulum.
PROCEDURE PERFORMED:
Endoscopic Zenker’s diverticulotomy.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA:
General endotracheal anesthesia.
ESTIMATED BLOOD LOSS:
Less than 10 mL.
SPECIMENS:
None.
COMPLICATIONS:
None.
FINDINGS:
The patient had a small, less than 2 cm Zenker’s diverticulum at the level of the cricopharyngeus.
INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old female suffering from dysphagia. A barium swallow was performed, which revealed a Zenker’s diverticulum. The plan was to take the patient to the operating room for an endoscopic Zenker’s diverticulotomy. The risks and benefits of the procedure, including esophageal perforation and mediastinitis, were explained to the patient. The patient expressed understanding of the risks and benefits and agreed to proceed with the procedure. Informed consent was signed.
DESCRIPTION OF PROCEDURE:
The patient came to the operating room and was placed in the supine position on the operating room table. General face mask anesthesia was given until a deep plane of anesthesia was obtained. At that point, an endotracheal tube was placed by the anesthesiology service without difficulty. The procedure began with a direct esophagoscopy. The direct esophagoscope was then placed in the oropharynx, hypopharynx to the proximal esophagus and passed to the distal esophagus. Working retrograde, the Zenker’s diverticulum was identified. The patient had a problem at the cricopharyngeal muscle. The Zenker’s diverticulum was small in nature.
At that point, the esophagoscope was removed. The Weerda scope was then placed into the oropharynx, hypopharynx, and proximal esophagus. Again, the cricopharyngeal muscle was identified, and the Weerda scope blades were opened to isolate the Zenker’s diverticulum and the esophagus. The Zenker’s diverticulum was too small to perform a stapling diverticulotomy. The decision was made to perform a diverticulotomy with the Harmonic scalpel. The Harmonic scalpel was used to perform the diverticulotomy, cutting the cricopharyngeal muscle and the remainder of the pouch. There was no evidence of perforation.
At the end of the procedure, a nasogastric tube was placed. Placement was confirmed with esophagoscope. At that point, the procedure was terminated. The patient was then awoken from general anesthesia, extubated, and sent to the postanesthesia care unit in stable condition.
