Rokitansky's diverticulum (midesophageal) is a rare nosological entity and a challenge of minimally invasive surgical resolution

Abstract

Introduction: Mid-esophageal diverticula are protrusions of the mucosa and submucosa through the muscular layer. Although historically associated with mediastinal inflammatory processes that caused traction (traction diverticula), they are currently also linked to underlying esophageal motility disorders (pulsion diverticula). Their clinical presentation ranges from asymptomatic to dysphagia, postprandial cough, regurgitation, and halitosis. Surgical management is indicated in symptomatic patients. Clinical case: We present a 76-year-old male patient with an 11-month history of symptoms (postprandial cough, dysphagia, halitosis). The diagnosis was confirmed via endoscopy and barium swallow, which revealed a 3.5 cm mid-esophageal diverticulum. A minimally invasive surgical approach was chosen. A laparoscopic and VATS (Video-Assisted Thoracic Surgery) diverticulectomy was performed. The procedure consisted of locating and dissecting the diverticulum, dividing its neck using a linear mechanical stapler, and reinforcing the suture line with seromuscular stitches. The postoperative period was uneventful, and oral intake was resumed on the fourth day following a follow-up esophagogram that ruled out leaks. The VATS approach is a safe and effective alternative to thoracotomy for the treatment of these diverticula, associated with lower morbidity and a faster recovery. Conclusions: This case underscores the importance of a comprehensive preoperative workup, ideally including esophageal manometry to detect underlying motility disorders. Performing a myotomy when these disorders are detected is crucial to address the primary cause and prevent recurrences, in addition to resolving the anatomical consequence.