ENDOSCOPIC SURGERY

OF ZENKER DIVERTICULUM
A Review of Current Techniques

Hilko WEERDA1, Konrad SOMMER2, Nicola WEERDA3

1
Prof. Hilko WEERDA, M.D., D.M.D.
Director Emeritus, Department of Otorhinolaryngology
and Plastic Surgery,
Schleswig-Holstein University, Medical Center, Lbeck Campus

2
Konrad SOMMER, M.D.
Chief of Staff, Department of Otorhinolaryngology,
Marienhospital, Osnabrck

3
Nicola WEERDA, M.D.
Senior Staff Member, Department of Otorhinolaryngology,
Freiburg University Hospital
Director: Prof. Roland Laszig, M.D., M.D. h.c.
4 Endoscopic Surgery of Zenkers Diverticulum

Endoscopic Surgery of Zenker Diverticulum

A Review of Current Techniques
Prof. Hilko WEERDA, M.D., D.M.D.
Konrad SOMMER, M.D.
Nicola WEERDA, M.D.

Illustrations and graphics: Addresses for correspondence:

Katja Dalkowski, M.D. Prof. Dr. med. Dr. med. dent. Hilko WEERDA
Grasweg 42 Emeritierter Direktor der Klinik fr HNO-Heilkunde und
91054 Buckenhof Plastische Operationen des Universittsklinikum
Germany Schleswig-Holstein, Campus Lbeck
E-mail: kdalkowski@online.de
Steinhalde 48, 79117 Freiburg, Germany

Cover page: Priv.-Doz. Dr. med. Konrad SOMMER

Sumo Nagi (Hilko Weerda, 1993) Chefarzt der Hals-Nasen-Ohrenheilunde, Kopf und Halschirurgie
Acrylic on fiberglass fleece, Marienhospital Osnabrck
mounted on wood, 44.5 cm x 52.5 cm Bischofsstrae,149074 Osnabrck

Dr. med. Nicola WEERDA

Oberrztin, Universittsklinik fr Hals-Nasen-Ohrenheilkunde
und Poliklinik Freiburg
Direktor: Prof. Dr. Dr. h.c. Roland Laszig,
Killianstrae 5, 79106 Freiburg, Germany

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Endoscopic Surgery of Zenkers Diverticulum 5

Table of Contents

1.0 Historical Development (Tab. 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.0 Symptoms and Diagnosis (Tab. 2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.0 Surgical Treatment Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

3.1 Method I (Lbeck Method) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3.1.1 Risk Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
3.1.2 Division of the Septum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3.1.3 Postoperative Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.4 Discussion of the Results (Tab. 3, 4) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.5 Complications (Tab. 5) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.5.1 Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.5.2 Residual Septum and Recurrences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1.5.3 Mediastinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2 Method II (Freiburg Method). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2.1 Method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.2.2 Results (Tab. 6) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

4.0 Summary and Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.1 Endoscopic Diverticulotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.2 Comparison of Methods I and II (the Lbeck and Freiburg Methods) . . . . . . . . . . . . . . 19
4.3 Risk Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.4 Recurrences (Tab. 1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
4.5 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

5.0 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Recommended Instrumentation and Video Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
6 Endoscopic Surgery of Zenkers Diverticulum
1.0 Historical Development
In 1769, LUDLOW published the
earliest description of a mucosal
pouch protruding through the
posterior wall of the pharynx.
ZENKER, in 1877, described five of
his own cases and 22 cases drawn
from other sources.
In 1908, KILLIAN described pulsion
diverticula occurring at the junction
of the hypopharynx and esophagus
(Figs. 1, 2a, b). He identified the
site of occurrence as a triangular
area of relative muscular weakness
located between the oblique and
transverse fibers of the crico-
pharyngeus muscle.
WHEELER described the first
surgical treatment of Zenker diver-
ticulum in 1885. The operation con-
sisted of a one-stage diverticulec-
tomy performed through an external
approach. Subsequent authors
described a variety of external
diverticulopexy and diverticulotomy
Fig. 1
Zenker diverticulum at the junction of the hypopharynx and posterior esophageal wall.
The protrusion occurs in a relatively weak triangular area between the oblique and
transverse fibers of the cricopharyngeus muscle. The pouch is located between the
esophagus and spinal column, often shifted slightly toward the left side (after WEERDA
1994).
techniques, which are outside our
present scope. In 1917, MOSHER
published the first report on an
endoscopic diverticulotomy the
endoscopic division of the com-
mon wall, or septum, between the
diverticular pouch and esophageal
lumen.
In 1932 SEIFERT recommended
using a scissors for endoscopic
diverticulotomy, and in 1943 DOHL-
MAN recommended using an elec-
trocautery.
After 1945, many surgeons in Ger-
many stopped performing endo-
scopic diverticulotomy due to
fears that it might cause potentially
fatal bleeding from an abnormally
placed right subclavian artery, infe-
rior thyroid artery or other large
vessel (LEGLER 1952). Surgeons
also reported numerous instances
of mediastinitis, poor functional
results, and recurrences (HERR-
Oblique fibers of the
cricopharyngeus
Killian triangle
Transverse fibers of the
cricopharyngeus
Recurrent laryngeal nerve
Esophageal muscle
MANN 1968, PAULSEN and KEIL
1970, DENECKE 1980, ESCHER
1984).
Outside of Germany, van OVER-
BEEK and HOEKSEMA (1982),
van OVERBEEK et al. (1984), and
HOLINGER and BENJAMIN (1987)
recommended the use of specially
designed rigid endoscopes with
a distal notch that could be used
to divide the septum with a laser
beam delivered to the operative site
through an operating microscope.
We have attempted to reestablish
these operative methods in
Germany as well.
With this in mind, we collaborated
with the KARL STORZ company
(Tuttlingen, Germany) to produce
a modified version of our laryngo-
scope (WEERDA 1978, WEERDA
and PEDERSEN 1981) with the
blade length extended to 24 cm.
Our goal was to minimize the risks
by combining this new design
with improvements in endoscopic
operating technique (WEERDA,
SCHLENTER et al. 1988, WEERDA
et al. 1989).
When we first presented our
reports at conferences in the late
1980s, they were met with skep-
ticism and prompted an intense
debate. Today, however, we note
that endoscopic diverticulotomy by
a variety of techniques has become
an established surgical procedure
(LAUBERT and LEHNHARDT 1989,
PROBST et al. 1992, LIPPERT and
WERNER 1995, ZBREN et al.
1999, N. WEERDA 2002 and 2003,
MATTINGER and HRMANN 2002,
SCHIPPER et al. 2006).
Endoscopic Surgery of Zenkers Diverticulum 7

The advantages of endoscopic Complications of diverticulectomy (with or without myotomy)

diverticulotomy over transcervical
compared with endoscopic surgery
(external) diverticulectomy are
documented in Tab. 1 (AHRENS External diverticulectomy Endoscopic
1993) and are summarized in with or without myotomy diverticulotomy using
Section 4 (see p. 14). Complications various techniques
MARTIN-HIRSCH and NEWBEGIN Patients (n) Complications Patients (n) Complications
(1993) and COLLARD et al. (1993) (%) (%)
described how a stapler developed Mortality 35/2270 1.5 7/991 0.7
for intestinal surgery could also be
used to perform an endoscopic Media stinitis 19/2188 0.9 15/988 1.5
Zenker diverticulotomy by simul- Bleeding 3/988 0.3
taneously dividing and stapling the
diverticular septum. Fistulas 91/2147 4.2
A modified form of this method Permanent recurrent
57/2235 2.5 2/973 0.2
was adopted at Freiburg University laryngeal nerve palsy
Hospital in 1994 (N. WEERDA et al. Recurrence 168/1860 9.0 74/784 9.4
2002 and 2003, SCHIPPER et al.
2006). Wound healing
109/2810 3.9
problems
In this booklet we will describe
both methods, which are referred Other 64/2239 2.9 22/988 2.2
to as method I or the Lbeck
Stenosis 14/2239 0.6 12/973 1.2
method (p. 8) and method II or the
Freiburg method (p. 16). We shall Cutaneous emphysema 22/988 2.2
review the results of each method Tab. 1
and evaluate them in our Conclu- Complications associated with diverticulectomy (with or without myotomy) compared
sion. In the Summary, we will also with endoscopic surgery. Review of the literature from 1945 to 1990 (from AHRENS 1993).
consider how both methods might
be effectively combined.

2.0 Symptoms and Diagnosis

Most older patients with a Zenker
diverticulum complain of dyspha-
gia ranging in severity from mild
swallowing difficulty to a complete
alimentary obstruction in the hypo-
pharynx. Other complaints are the
frequent regurgitation of undi-
gested, often foul-smelling food
residues and aspiration with occa-
sional episodes of pneumonia.
Patients experience weight loss
and may become severely emaci-
ated.
Radiographic examination after
oral contrast administration (Figs.
2a, b) displays typical findings,
especially in the lateral projec-
tion. BROMBART (1973) classified
the radiographic findings into four
stages based on the severity of the Fig. 2a Fig. 2b
AP radiograph of a large Zenker diverticulum Lateral radiograph of the diverticulum
protrusion (Fig. 3, Tab. 2). (BROMBART stage IV, see Fig. 3).
filled with contrast medium.
8 Endoscopic Surgery of Zenkers Diverticulum

Each patient undergoes a thorough

medical examination and endos-
copy.

BROMBART (1973) classified

Zenker diverticula into the follow-
ing four stages based on the
degree of protrusion in the lateral
oral contrast radiograph (see
Fig. 3):

Stages I and II: intermittent

spur- or club-shaped protrusion.
Surgery is not required.
I II III IV Stage III: persistent saccular
protrusion at least 1 cm long that
Fig. 3
Classification of diverticula based on their appearance in the lateral radiograph after oral does not compress the esopha-
contrast administration (BROMBART 1973; see Tab. 2). gus. Treatment is indicated only
if the patient is symptomatic.
Stage IV: large retroesophageal
Radiographic staging of Zenker diverticula (BROMBART 1973)
pouch that is constantly filled
BROMBART with contrast medium and is
stages I II III IV
compressing the esophagus.
Number of
n=0 n=2 n = 27 n = 39 Surgical treatment is indicated.
patients (n = 68)
Tab. 2
Radiographic Brombart stages of Zenker diverticula in the Lbeck series (n = 68 patients).
Stage I = small protrusion that disappears during swallowing. Stage II = diverticulum still
visible when the esophagus is at rest. Stage III = saccular protrusion at least 10 mm long.
Stage IV = large pouch compressing the esophagus.

3.0 Surgical Treatment Methods

3.1 Method I (Lbeck Method)
Microsurgical diverticulotomy with
a CO2 laser and the WEERDA
distending diverticuloscope using
sutures and glue for mediastinal
closure.
The patient is placed under gene-
ral anesthesia, preferably by nasal
intubation, and the diverticular
pouch is reinspected by endoscopy
prior to the operation. The pouch is
cleaned and flushed with antiseptic
solution if necessary, and a gastric
tube is placed under vision.
Next the WEERDA distending diver-
ticuloscope (Fig. 4a, KARL STORZ
12067 A) is introduced, passing one
blade into the diverticular pouch
and the other into the esophagus.
When the blades are in position,
they are spread open so that the
septum and fundus of the diver-
ticulum can be clearly visualized
(Figs. 5a, b; 8a).
The RIECKER-KLEINSASSER laryn-
goscope holder (KARL STORZ 8575
GK; Figs. 4b and 6b) is attached
to the scope and is placed on the
Lbeck-model chest support (Figs.
6a, b, KARL STORZ 8585 S). The
chest support has a fine gear-and-
thread mechanism for adjusting the
height of the support plate and lock-
ing it in place. At that point the posi-
tion of the diverticuloscope blades
can be readjusted (Fig. 5b).
Endoscopic Surgery of Zenkers Diverticulum 9

Fig. 4a Fig. 4b Fig. 5a

WEERDA distending diverticuloscope. WEERDA distending diverticuloscope with Intraoperative view of the septum after
the RIECKER-KLEINSASSER laryngoscope opening the blades of the diverticuloscope.
holder attached.

Fig. 5b
The septum of the Zenker diverticulum is
stretched taut by the opened blades of the
diverticuloscope. The fundus of the
Fig. 6a diverticulum is below (photograph taken
Chest support, Lbeck model, with an with a HOPKINS 0 straight forward
adjustable, locking metal plate for telescope, KARL STORZ).
supporting the laryngoscope holder and
wire ring (suspension device for placing
tongue blades, retractors, etc.). The thread
mechanism and swivel arm can be precisely
adjusted for the optimum positioning of
various endoscopes (see Fig. 6b; KARL
STORZ 8585 S) without exerting pressure
on the patients chest.

Fig. 6b
The diverticuloscope in place, suspended
by the RIECKER-KLEINSASSER laryngo-
scope holder on the Lbeck model chest
support (old model, see Fig. 6a).
The patient is intubated transnasally and
draped, and moist compresses are packed
around the endoscope to prevent laser
burns (see Fig. 14b).
10 Endoscopic Surgery of Zenkers Diverticulum

Fig. 7
A Doppler ultrasound unit (commercially available) can be used to scan the diverticular
septum for atypical blood vessels. The small ultrasound probe is clipped to a special
introducer rod (KARL STORZ 12067 U).

3.1.1 Risk Reduction

In early endoscopic surgery, there
were repeated reports of severe
intraoperative bleeding (LEGLER
1952, MATTINGER and HRMANN
2002), mediastinitis, and fistula
formation (AHRENS 1993, KRESPI
et al. 2002) that caused many
surgeons to abandon this type of
operation.
Fig. 8a
Diverticular septum stretched between the
opened blades of the diverticuloscope. This prompted us to find ways to
advance the endoscopic tech-
nique and minimize its risks.

Excluding blood vessels in the

septum (see Fig. 7)
We felt that the easiest way to
check the diverticular septum for
blood vessels would be to scan the
septum with a small Doppler ultra-
sound probe (Fig. 7).
A special introducer rod with a distal
probe clip has been developed
for this application (Fig. 7, KARL
STORZ 12067 U).

Suturing and sealing the cut

Fig. 8b edges with fibrin glue
Stretched diverticular septum (S). Moistened gauze strips are packed into the esophagus (O) (Tissucol, Baxter, Heidelberg; see
and diverticular pouch (D) to prevent laser burns (from AHRENS 1993). The gauze strips are
progressively removed (see Fig. 9a). Figs. 12a, b and 14a, b).
Endoscopic Surgery of Zenkers Diverticulum 11

3.1.2 Division of the Septum

The face should be completely
covered during the laser surgery,
and the towels or gauze com-
presses around the diverticulo-
scope should be moistened (Figs.
5a, 14b). Small, moist gauze stripe
are introduced with the WEERDA
grasping forceps (KARL STORZ
12067 W, Fig. 9b) to protect the
esophagus and diverticular mucosa
from accidental laser burns (Figs.
8b, 9a; WEERDA 1993, WEERDA
and SOMMER 2001).
The CO2 laser beam is delivered to
the operative site through the micro-
scope, and the septum is carefully
and accurately divided down the
center under optimum vision using
noncontact laser technique (Fig. 9a;
WEERDA et al. 1988, 1989, SOM-
MER et al. 2001).
If necessary, excess mucosa can
be grasped with the small forceps
(Fig. 9b) and resected with the
laser. This is particularly common
with large diverticula. The forceps
has a built-in suction channel to
maintain clear exposure of the
operative site.
In the next step when the sutures
are placed, the mucosa of the diver-
ticular fundus can be pulled upward
slightly to create a smoother junc-
tion with the rest of the esophagus
(see Fig. 15b).

Fig. 9a
Division of the septum with the CO2 laser.
The moist gauze strips packed in the pouch
and esophageal lumen are progressively
removed.

Fig. 9b
WEERDA grasping forceps has double-
action alligator jaws with 1 x 2 teeth and
a built-in suction channel for evacuating
laser plume. Useful length = 30 cm. The
handle is fitted with a stop mechanism for
locking the jaws in place (KARL STORZ
12067 W). The instrument is used like a
forceps.
Insert: close-up view of the jaws with
integrated suction channel.
12 Endoscopic Surgery of Zenkers Diverticulum

Fig. 10a Fig. 10b

Extra-long, slender clip-applying forceps, designed by the authors for the intraluminal Jaws of the extra-long, slender forceps for
application of small PDS clips (Fig. 11a) (KARL STORZ 12067 TL and TR for left L and applying PDS clips (shown here with a small
right R). vascular clip).

Placing the lateral sutures and

sealing the mediastinum with glue
In 1994 we began suturing the
wounds in the lateral wall to the
fundus in addition to sealing
the cut edges and mediastinum
with glue. The wounds lines are
sutured with 4-0 PDS (Ethicon,
Norderstedt, Germany). To avoid
tedious knot tying at long range,
we place a small PDS vascular clip
a (KARL STORZ 12067 TT, Figs. 10a,
b) on the end of the suture with
the clip applicator (Figs. 10a, b,
KARL STORZ 12067 TL, left, or TR,
right) before the sutures are placed.

Figs. 11a, b
Extra-long needle holder (inset: KARL STORZ 12067 ML = angled to the left, 12067 MR
= angled to the right) for endopharyngeal suturing, shown with a needle clamped in place
and with a PDS vascular clip on the end of the suture instead of a knot (a) (4-0 PDS suture
with a P3 needle, Ethicon, Norderstadt, Germany).
Endoscopic Surgery of Zenkers Diverticulum 13

Next the continuous suture lines are

placed using the extra-long needle
holders angled 90 to the left or
right (Fig. 11a, KARL STORZ 12067
ML [left] or MR [right]). Finally the
running sutures are secured intra-
luminally by placing a small PDS
vascular clip (Fig. 10b) on the ends
of each suture line with the clip-
applying forceps (Fig. 10a); this
eliminates the need for tedious knot
tying. The PDS suture material and
clips will be reabsorbed or expelled
over time and are no longer visible Fig. 12a Fig. 12b
after 68 weeks. Schematic lateral view of the pharyngeal and Schematic anterosuperior view after the
diverticular walls after endoscopic diverticu- lateral mucosal edges have been sutured.
lotomy and suture closure of the mucosal The suture ends have been secured with
Sealing the Wounds and edges. The black arrows indicate the path of vascular clips instead of knots.
the food bolus. Note the small clips on the
Mediastinum with Fibrin Glue suture ends (after WEERDA and SOMMER
2001).
We also recommend sealing the
wounds with fibrin glue (Tissucol,
Baxter, Heidelberg) to secure the
suture lines and mediastinum.
Double tubing is cut to a length of
approx. 32 cm and is connected
to the hub of the double-barreled
syringe, which contains the fibrin
glue components (Fig. 14a). The
distal end of the tubing is gripped
with a small grasping forceps
(Fig. 9b, KARL STORZ 12067 W)
and passed through the diverti-
culoscope to the wound margins,
where the fibrin glue is injected Fig. 13
under microscopic control to rein- Intraoperative view following division and
suture closure of the lateral mucosal edges
force the suture lines and seal the of the diverticulum and hypopharynx (from
mediastinum (Fig. 14b). SOMMER et al. 2001; see also Figs. 12a, b).

Fig. 14a Fig. 14b

Double-barreled syringe with fibrin glue components. Double The double tube is positioned under microscopic control.
tubing is cut to a length of approximately 32 cm (Tissucol, Baxter, (Here, the area around the mouth is still covered with moist gauze.)
Heidelberg) and passed through the diverticuloscope with the
WEERDA grasping forceps (KARL STORZ 12067 W, see Fig. 9b).
14 Endoscopic Surgery of Zenkers Diverticulum

3.1.3 Postoperative Care

Gastric Tube
If a gastric tube was not placed
transnasally before the operation,
it can now be passed down the
esophagus and into the stomach
under vision, directing it past the
operative site. Some air is insuf-
flated to confirm intragastric place-
ment. Our patients are monitored
overnight in the recovery room.
Antibiotics
We routinely give perioperative anti-
biotics for medicolegal reasons.
The American literature does not
describe the use of prophylactic
antibiotics. SCHIPPER et al. (2006)
give antibiotics only in patients with
fever or suspected incipient medi-
astinitis.
Postoperative Radiographs
We obtain radiographs with aque-
ous oral contrast medium on
the third or fourth postoperative
day (first postoperative day in the
Freiburg method), at which time the
gastric tube is removed. A liquid
diet is given initially, and the patient
is discharged on the fifth or sixth
postoperative day (SOMMER et
al. 2001). This is also done in the
Freiburg method (SCHIPPER et al.
2006; see Tab. 6).
A different protocol is followed in
the U.S., where generally a gastric
tube is not used. A liquid diet is pre-
scribed for one week, and patients
who are doing well are discharged
home on the first or second post-
operative day (Tab. 6). Based on
the results in the U.S., it may be
well to consider a shorter period
of inpatient postoperative care in
Germany as well (BRADWELL et
al. 1997, SCHER and RICHTS-
MEIER 1998, COOK et al. 2000,
PHILIPPSEN et al. 2000, SMITH et
al. 2002).
Endoscopic Follow-Up
We schedule an endoscopic follow-
up examination no earlier than 68
weeks after the operation.

3.1.4 Discussion of the Results

A total of 68 patients with a Zenker
Subjective rating of outcomes
diverticulum were treated at Lbeck
University Hospital from 1987 to n = 64 %
2001. Sixty-four of these patients
underwent a transoral laser diverticu-
lotomy, and the other four underwent
I
II
Satisfied
Improved
57
6
89.1
9.4 } 98.5%

transcervical surgery for various III Dissatisfied 1 1.5

reasons (4/68 patients = 5.9%).
In 1994 we began suturing and
gluing the lateral wounds and fundus
using the technique described above
(group II = 26 patients).
The average operating time was
30 minutes.
Three of the patients required a second diverticulotomy,
and one required a third operation.
Tab. 3
Subjective outcome ratings in 64 patients who underwent endoscopic surgery between
1987 and 2001. Fifty-seven patients (89%) reported normal swallowing function on the
4th postoperative day, and 6 patients (ca. 9%) reported significant improvement.
Group I, in which the old pre-1994 technique was used, included 3 patients who required
one or two endoscopic reoperations for residual septum to obtain a satisfactory result.

Residual septa were most com-

monly seen in radiographs of the
38 group I patients. Only three of
the patients had functionally signi-
ficant residual septa that required
additional endoscopic surgery (see
Tab. 3).
Endoscopic Surgery of Zenkers Diverticulum 15

Two of four patients with relatively

Postoperative radiographs
mild postoperative dysphagic
complaints were found to have no n = 64 %
residual septa. In the other eight Residual septum 14 22
patients, six reported no swallowing
Tab. 4
difficulties. It is noteworthy that Evidence of a residual septum on postoperative radiographs taken on the third or fourth
oral contrast radiographs in almost postoperative day.
all the patients showed a marked
expansion of the esophagus at the
operative site, which regressed
significantly over a period of one
year (Fig. 15b).

3.1.5 Complications
3.1.5.1 Bleeding
Significant bleeding did not occur.
We were able to exclude blood
vessels larger than about 1 mm in
diameter by scanning the septum
with a Doppler probe (Fig. 7; Sono-
vit SV-1, Schiller, Baar, Switzer-
land). Smaller vessels were sealed
by the laser during the diverticu-
Fig. 15a Fig. 15b
lotomy. Preoperative lateral radiograph of a large Postoperative radiograph still shows an
Small bleeders were occasionally Zenker diverticulum filled with contrast expansion at the level of the diverticular
medium. pouch, which generally disappears by
encountered during division of the about one year. The fundus of the pouch
muscle and were controlled with a was pulled upward during suturing,
resulting in a favorable angle at the
unipolar suction-cautery tip (KARL esophageal junction (see p. 10).
STORZ 12067 R or P, length 30 cm,
or KARL STORZ 37270 SC).
Complications of endoscopic diverticulotomy
n = 64 %
Mediastinitis* 1 1.6
Fever
Suspected mediastinal irritation 34 53.1
Transient, unilateral
recurrent laryngeal nerve palsy 1 1.6

Tab. 5
Complications of endoscopic diverticulotomy (see also Tab. 1).
* Patient from group I.
16 Endoscopic Surgery of Zenkers Diverticulum

3.1.5.2 Residual Septum and Recurrences (Tab. 3, 4)

It is unclear why diverticula occa- action during swallowing. In our
Radiographic evidence of a slight
sionally recur shortly after the oper- later group of 26 patients (group II),
residual septum with no func-
ation. This may result from a too in which the septum was divided
tional significance may be dis-
tentative division of the diverticular into the fundus and the mediasti-
regarded (SOMMER et al. 2001).
septum, or it may involve a predis- num and cut edges were sutured
position to diverticulum formation and also sealed with glue, there
due to uncoordinated muscular were no instances of recurrence.

3.1.5.3 Mediastinitis (Tab. 5)

A mild postoperative temperature
elevation (noted in 31 of 64 patients)
may occur. In the early patient group
whose wounds were not sutured
and were closed only with glue, we
observed one case of mediastinitis
that responded well to an antibiotic
combination.
One of 64 patients (68 operations) the indications and disadvantages
experienced transient recurrent of endoscopic diverticulotomy after
laryngeal nerve palsy with hoarse- discussing the Freiburg method.
ness, which resolved in 6 weeks.
Residual expansion of the esopha-
gus seen on oral contrast radio-
graphs (Fig. 15b) will generally
regress over time. We will review

3.2 Method II (Freiburg Method)

Microsurgical diverticulotomy
with a stapler (Endo GIA 30, Fig.
16a) using the WEERDA diverticu-
loscope.
In 1993, COLLARD et al. and
MARTIN-HIRSCH and NEWBEGIN
described their experience with
a one-stage method for simulta-
neously dividing the diverticular
septum and sealing the cut edges.
They used a stapler developed for
intestinal surgery (Endo GIA 30,
Tyco Healthcare). This method
was adopted at Freiburg Univer-
sity Hospital in 1994 and was later
modified for use on Zenker divertic-
ula (N. WEERDA et al. 2002, 2003,
SCHIPPER et al. 2006).

Fig. 16a
MULTIFIRE ENDO GIA 30 stapler with
interchangeable cartridges. Instrument
length 31.5 cm, barrel diameter 1.2 cm,
cartridge length 3.5 cm.

Fig. 16b
Close-up view of the staple cartridge
(length 3.5 cm). Each half of the cartridge
carries three staggered rows of staples,
separated from the opposing half by a
central knife blade. The original distal end
is 1 cm long.
Endoscopic Surgery of Zenkers Diverticulum 17

3.2.1 Method
This method is suitable only for
diverticula larger than 2 cm (van
EEDEN et al. 1999, COOK et al.
2001, SCHIPPER et al. 2006).
Preparation and insertion of the
diverticuloscope are the same as in
method I (see p. 8) and should be
preceded by the insertion of a naso-
gastric tube. Fig. 16c
Head of the stapler cartridge with the blades opened. Tissue cannot be divided and stapled
along the 1-cm-long distal end of the cartridge. (MULTIFIRE ENDO GIA 30 stapler, Tyco
Endoscopic Inspection Healthcare.)
of the Septum
In the stapler developed for gastro-
intestinal surgery (Figs. 16ac), the Checking the Position of the Division of the Septum
distal end of the staple cartridge Stapler Head (Fig. 17) The surgeon squeezes the trigger
forms a tapered projection approx. The accurate placement of the on the pistol grip (Fig. 16a) to acti-
1 cm long. The Freiburg surgeons closed stapler head is checked vate the cutting and stapling mech-
have shortened the distal end to with the 0 or 30 telescope (KARL anism. When fired, the stapler cuts
5 mm so that it can be passed STORZ 27005 AA and 27005 BA). through the septum and tightly seals
deeper into the diverticular pouch. The blades of the diverticuloscope the cut edges to the left and right of
First the diverticulum is inspected should be opened as widely as pos- the myotomy, simultaneously seal-
with the HOPKINS 0 telescope sible at this time to facilitate stapler ing the blood vessels in the lateral
(KARL STORZ 27005 AA) to exclude inspection (N. WEERDA et al. 2002, edges. The stapler is removed, and
pulsating vessels in the septum. 2003, SCHIPPER et al. 2006). the staple lines are microscopically
Then the opened stapler is passed inspected (Fig. 18).
over the septum, placing it as deep
in the diverticulum as possible, and
the blades of the stapler are closed.

Fig. 17 Fig. 18
The blades of the Endo GIA stapler have been clamped over the Postoperative appearance of the divided and stapled septum.
septum. Vision is somewhat limited by the 12-mm diameter of the
stapler barrel.
18 Endoscopic Surgery of Zenkers Diverticulum

Repeating the Diverticulotomy Postoperative Radiographs Mediastinitis

If the stapler is not advanced far
enough into the diverticulum or
if the pouch is too large, a signifi-
cant residual septum will remain.
In this case the stapler cartilage is
replaced with a new sterile carti-
lage, and the residual septum is
divided and stapled.
Postoperative Surveillance
The patient spends approximately
24 hours in the recovery room. The
blood count and temperature are
monitored during this time.
Oral contrast radiographs are taken Patients with chest pain, headache,
on the first postoperative day in fever, or inflammatory laboratory
patients with an uneventful course. parameters (WBC, CRP) should be
On the sixth day the nasogastric evaluated by radiography or even
tube is removed and the patient is computed tomography (SCHIPPER
discharged home. Follow-up office et al. 2006).
visits should be scheduled at one
week and again at one year. Anti-
biotics are contraindicated to
avoid masking signs of incipient
mediastinitis.

3.2.2 Results Number of Duration of Hospital Time to

patients who operation (%) stay initiation of
The operating method was modified Literature underwent endoscopic (min.) (days) liquid diet
in 1998, and a total of 61 patients stapler surgery (days)
underwent the modified procedure KOAY, BATES
from 1998 to 2003. The average 14 14.3 2.2 1
1996
patient age was 65.6 years (2795
BALDWIN, TOMA
years). (51) 1.53
1998
In two patients (3.2%) the septum SCHER,
could not be visualized, and RICHTSMEIER 36 40 1.3 0.51
external surgery was performed. 1998
The septum was smaller than 2 cm OMOTE et al.
in two patients and was divided with 21 22 4.7 12
1999
the CO2 laser. The average duration
NARNE et al.
of the operation was 17 minutes 102 20 4.0 2
1999
(Tab. 6).
COOK et al.
74 35 1.15 0.20.8
Mediastinitis 2000
Four patients were examined by PHILIPPSEN et al.
14 33 3.5 1
thoracic radiography or CT to 2000
investigate rising inflammatory SMITH, URKEN
8 25 1.3 0.8
parameters. Two patients with 2002
suspected mediastinitis received a Freiburger Kollektiv:
7-day course of antibiotic therapy. SCHIPPER et al. 61 17 6 1.2
One patient developed mediastini- 2006
tis due a perforation, and this case Total or average 330 ca. 31 3.3 13
had a fatal outcome (1.6%).
Tab. 6
Recurrences Survey of the literature and the Freiburg series comparing the length of the operation,
hospital stay, and time to initiation of a liquid diet (modified from SCHIPPER et al. 2006).
Ten patients (16.4%) experienced
a recurrence of dysphagic symp-
toms and regurgitation within
12 months after the operation. The
stapler myotomy was repeated in
all ten of these patients, and there
were no further instances of recur-
rence thereafter.
Endoscopic Surgery of Zenkers Diverticulum
4.0 Summary and Discussion
The transcervical surgery of
Zenker diverticulum is a time-con-
suming (90 min to 3 hours), trauma-
tizing and stressful operation for
most older patients. Surgery for a
recurrent diverticulum is difficult
due to scarring and the proximity
4.1 Endoscopic Diverticulotomy
This operation was first described
by MOSHER in 1917 and was
introduced in Germany by SEIFERT
in 1932.
Endoscopic diverticulotomy was
rejected during the 1950s due to
limited visualization of the opera-
tive site and the potential for fatal
complications. Outside of Germany,
endoscopic laser diverticulotomy
using broader, rigid endoscopes
was reintroduced by van OVER-
BEEK in the Netherlands in 1984
and by HOLINGER and BENJAMIN
in the U.S. in 1987.
Van OVERBEEK (1994), ZBREN
et al. (1999), and SCHER (2003)
4.2 Comparison of Methods I and II (the Lbeck and Freiburg Methods)
Dividing the septum and simulta-
neously sealing the cut edges with
a stapler (Freiburg method) is an
elegant, appealingly simple and
rapid procedure that takes approx-
imately 17 minutes, compared with
30 minutes using the suture-and-
glue technique (Lbeck method).
The operating times reported in the
literature (Tab. 6) range from 14 to
40 minutes, with an average dura-
tion of 31 minutes (Tab. 6).
of large vessels. The morbidity and
mortality are higher than with endo-
scopic methods, as comparative
studies and meta-analyses have
shown (Tab. 1; WEERDA et al. 1989,
WEERDA 1993, AHRENS 1993, van
OVERBEEK 1994, NGUYEN and
have noted the significant advan-
tages of endoscopic surgery, which
include lower morbidity, more rapid
convalescence, shorter operating
times, and shortened hospital stays
(Tab. 6). Van OVERBEEK (1994)
described the advantages of endo-
scopic diverticulotomy in a series
of 545 patients, even without rein-
forced closure of the wound edges.
By working with KARL STORZ to
develop new instruments, espe-
cially the distending diverticulo-
scope, and by minimizing the surgi-
cal risk (WEERDA et al. 1988, 1989,
2001; SOMMER et al. 2001), we
have attempted to restore endo-
With large diverticula, the cartridge
should be exchanged when the
stapler method is used. The distal
end of the standard cartridge is
1 cm long (Fig. 16c), causing the
instrument to leave a significant
residual septum. This may account
for the relatively high recurrence
rate of 16.4% in the Freiburg
method. There have been occa-
sional reports of perforations by
the stapler tip (BRADWELL et al.
19
URQUHART 1997, BONAFEDE
et al. 1997, ZBREN et al. 1999,
SOMMER et al. 2001, SCHIPPER
et al. 2006). Endoscopic surgery
for recurrent diverticula is free of
these problems (SCHEER 2003).
scopic diverticulotomy as an estab-
lished surgical option in Germany
(Lbeck method I).
In 1993, COLLARD et al. and
MARTIN-HIRSCH and NEWBEGIN
described an elegant modifica-
tion in which a stapler developed
for intestinal surgery was used to
simultaneously divide the diverticu-
lar septum and seal the cut edges
(Fig. 16a).
In 1994 this method was adopted
and modified at the Freiburg center
(N. WEERDA et al. 2002 and 2003,
SCHIPPER et al. 2006), giving rise
to the Freiburg method.
1997, HILTON and BRIGHTWELL
2000, COOK et al. 2000, MIRZA et
al. 2002, N. WEERDA et al. 2002,
2003, SCHIPPER et al. 2006).
The large, 12-mm diameter of the
stapler barrel is a distinct disad-
vantage, making it difficult to visua-
lize the septum and fundus. This
may even be responsible for the
occasional perforations that have
occurred (Fig. 17).
20
4.3 Risk Reduction
The septum should be scanned
with a Doppler probe (Fig. 7) when
the stapling method is used. This
provides a rapid and simple means
of excluding large blood vessels,
4.4 Recurrences (Tab. 1)
Transcervical surgery is associated
with a 9.0% recurrence rate, and
the endoscopic techniques have
an overall recurrence rate of 9.4%.
Compared with these figures, the
recurrence rate of 16.4% in the
Freiburg method is remarkably
high. MATTINGER and HRMANN
(2002) described similarly high
recurrence rates (8 of 52 patients =
15.4%) following diverticulotomies
performed with a scissors or laser.
No recurrences occurred following
the suture-and-glue closures in
Lbeck group II (0 of 26 patients).
In the Freiburg method, the 1-cm-
4.5 Conclusion
IIf the diverticular septum can be
visualized with the distending diver-
ticuloscope, the method of choice
is endoscopic diverticulotomy
with the microscopically controlled
CO2 laser or stapler.
Carrying the incision into the fundus,
sealing the wound margins, hitching
up the fundus, and resecting excess
mucosa appear to be the best ways
to lower the risk of recurrence and
prevent mediastinitis (WEERDA
Endoscopic Surgery of Zenkers Diverticulum
thereby minimizing the risk of intra-
and postoperative bleeding.
Cutaneous emphysema has a
reported incidence of 2.2% in
endoscopic surgery (Tab. 1), but
long distal end of the staple car-
tilage (Figs. 16ac) leaves a signi-
ficant residual septum. It is also
conceivable that the divided part
of the septum may grow back
together, especially in its lower
portion.
Because the laser cut in the Lbeck
method extends into the diverticu-
lar fundus and any excess mucosa
is resected (SOMMER et al. 2001),
suturing the wounds prevents the
edges of the septum from growing
back together (Figs. 12a, b). Also,
the mediastinum is sealed under
microscopic control. The fundus
et al. 1988, 1989, WEERDA 1993,
SOMMER et al. 2001, N. WEERDA
et al. 2002, 2003, SCHIPPER et al.
2006).
With a suitable oral diet, the gastric
tube can be removed as early as the
first or second postoperative day.
The length of hospital stay ranges
from 1 to 6 days in the literature
(SMITH et al. 2004). The bleeding
risk can be minimized by scanning
the septum with a Doppler probe
this complication did not occur after
any of the staple or suture closures
in the Lbeck series.
can be pulled upward when the
sutures are placed, creating a favor-
able oblique junction with the rest of
the esophagus (Fig. 15b).
In the Freiburg method, the distal
end of the staple cartridge (Figs.
16ac) should be substantially
shortened in order to minimize
the residual septum. If this is not
possible, we suggest dividing the
residual septum with a laser, scis-
sors, or electrocautery and closing
the cut edges with sutures and
tissue adhesive (COOK et al. 2000,
SOMMER et al. 2001).
to check for relevant blood vessels
before the septum is divided.
From a surgical standpoint and
for medicolegal reasons, these
methods that emphasize wound
management are preferred over
methods that involve simple
division of the septum!
Endoscopic Surgery of Zenkers Diverticulum
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with more established procedures for pharyngeal
pouches: results and patient satisfaction survey.
Department of Otolaryngology, Royal Sussex
County Hospital, Brighton, UK. Laryngol Otol
1999; 113:23740.
41. VAN OVERBEEK JJ, HOEKSEMA PE: Endoscopic
treatment of the hypopharyngeal diverticulum: 211
cases. Laryngoscope 1982; 92: 8891.
42. VAN OVERBEEK JJ, HOEKSEMA PE, EDENS ET:
Microendoscopic surgery of the hypopharyngeal
diverticulum using electrocoagulation or carbon
dioxide laser. Ann Otol Rhinol Laryngol 1984;
93:346
43. VAN OVERBEEK JJ: Mediation on the pathoge-
nesis of hypopharyngeal (Zenkers) diverticulum
and a report of endoscopic treatment in 545
patients. Department of Otorhinolaryngology,
University Hospital, Groningen, The Netherlands.
Ann Otol Rhinol Laryngol. 1994; 103:17885.
44. WEERDA H, PEDERSEN P, WEHMER H, BRAUNE
H: A new laryngoscope for endolaryngeal micro-
surgery. A contribution to injector respiration.
Arch otorhinolaryngol. 1979: 225: 103677.
45. WEERDA H, PEDERSEN P: Ein neues Spreiz-
laryngoskop fr die endolaryngeale Diagnostik
und Mikrochirurgie HNO 1981; 29: 5863
46. WEERDA H, SCHLENTER WW, AHRENS KH,
BACH-QUANG M: Neues Divertikuluskop zur
Schwellendurchtrennung des Zenkerschen
Divertikels mit dem CO2-Laser (A new distending
diverticuloscope for endoscopic treatment of
Zenkers diverticulum with the CO2-Laser).
Arch Otolaryngol 1988; 245384 und Arch
Otorhinolaryngol 1988; II: 269271
47. WEERDA H, AHRENS KH, SCHLENTER WW:
Manahmen zur Verringerung der Komplikations-
rate bei der endoskopischen Operation des
Zenkerschen Divertikels. Laryngo-Rhino-Otol
1989; 68: 675677.
23
48. WEERDA H: Spreizdivertikuloskop n. WEERDA:
Ein Beitrag zur minimal invasiven Chirurgie des
Zenkerschen Divertikels mit dem CO2-Laser
(Distending Diverticuloscope: A contribution
towards minimal invasive surgery of Zenkers
diverticulum using a CO2-Laser)
EndoWorld: KARL STORZ, HNO Nr. 12-D, 1993
(EndoWorld: KARL STORZ, OR Nr. 12E, 1993)
49. WEERDA H: Distending Diverticuloscope,
Instruments and the Technique for Endoscopic
CO2-laser Surgery. EndoWorld: KARL STORZ,
HNO Nr. 50D-2001
50. WEERDA H: Hals-, Nasen- Ohrenheilkunde.
Enke-Verlag Stuttgart, 1994; 2. Aufl. S. 170
51. WEERDA H, SOMMER K: Ein neues Instrumen-
tarium und eine neue Technik fr transorale
laserchirurgische Schwellendurchtrennung zur
Behandlung des ZENKER-Divertikels. Endo-World:
KARL STORZ, HNO Nr.50/1-D 2001
52. WEERDA N, ASCHENDORF A, SCHIPPER
J, MAIER W, LASZIG R: Die endoskopische
Schwellendurchtrennung beim Zenkerschen
Divertikel mittels Endo-GIA als therapeutsiche
alternative. Vortrag 2. Jahrestagung der Nord-
deutschen Gesellschaft fr Oto-Rhino-Laryngo-
logie und zervikofaziale Chirurgie vom 12.-14.4.
2002 in Lbeck und auf dem 33. Kongress der
deutschen Gesellschaft fr Endoskopie mit
Bildgebende Verfahren vom 3.4.-5.4.2003 in
Dsseldorf.
53. WHEELER W: Pharyngocele and dilatation of the
pharynx with extending diverticulum in the lower
portion of pharynx lying posterior to the
esophagus, cured by pharyngotomy. Dublin J
Medical Science 1886; 83: 349356.
54. ZBREN P, SCHR P, TSCHOPP L, BECKER M,
HUSLER R: Surgical treatment of Zenkers
diverticulum: transcutaneous diverticulectomy
versus microendoscopic myotomy of the
cricopharyngeal muscle with CO2 laser.
Department of Radiology, University Hospital,
Geneva, Switzerland. Otolaryngol Head Neck Surg
1999; 121: 4827.
55. ZENKER FA: Krankheiten des sophagus In:
Ziemsen H von (Hrsg) Handbuch der speziellen
Pathologie und Therapie. Vogel Verlag, Bd. 7/Teil
1: 1877, Leipzig, 5087.
24 Endoscopic Surgery of Zenkers Diverticulum

WEERDA Distending Diverticuloscope

for CO2 Laser Technique

8575 K

8590 GF

8590 ML

12067 A 12067 M

Outer dimensions in mm: 12067 A WEERDA Distending Diverticuloscope,

proximal: length 24 cm, with adaption for suction tube 12067 M
27 Proximal size open: max. 40 x 27|mm
min. 29 x 27|mm
Distal size open: max. 65 x 18|mm
12067 A min. 7 x 18|mm
8590 GF Fiber Optic Light Carrier, for distal illumination, working length 14 cm,
for use with Laryngoscopes 8588 BV, 8590 A-JN, 8590 T, 8590 JV/TV
and Diverticuloscopes 12067 A, 12068 A
Spread: max. 40,
min. 29
8590 ML Suction Tube, to remove vapor, for LASER treatment,
outer diameter 3|mm
12067 M Suction Tube, to remove vapor, flat, size 6 x 3 mm
distal: 8575 K Laryngoscope Holder and Chest Support, GTTINGEN model,
18 including:
Laryngoscope Holder, GTTINGEN model, with adjustment wheel
12067 A Support Rod, movable, with metal ring, diameter 9 cm, length 34 cm
or
Spread: max. 65, 8575 KC BENJAMIN-PARSONS Laryngoscope Holder and Chest Support,
min. 7
including:
Laryngoscope Holder GOETTINGEN model, with adjustment wheel
BENJAMIN-PARSONS Support Rod, movable, with metal ring,
diameter 12 cm and 2 lateral set screws, length 34 cm

It is recommended to check the suitability of the product for the intended procedure prior to use.
Endoscopic Surgery of Zenkers Diverticulum 25

WEERDA Distending Diverticuloscope

for Stapling Technique
for use with
HOPKINS Straight Forward Telescope 10005 AA

8575 K

8590 GF

12067 B

10005 AA

Outer dimensions in mm: 12067 B WEERDA Distending Diverticuloscope,

proximal: length 24 cm, without adaptor for Suction Tube 12067 M
27 Proximal size open: max. 40 x 27|mm
min. 29 x 27|mm
Distal size open: max. 65 x 18|mm
min. 7 x 18|mm
12067 B
10005 AA HOPKINS Straight Forward Telescope 0,
enlarged view, diameter 4 mm, length 30 cm, autoclavable,
fiber optic light transmission incorporated,
Spread: max. 40, color code: green
min. 29
10005 BA HOPKINS Forward-Oblique Telescope 30,
enlarged view, diameter 4 mm, length 30 cm, autoclavable,
fiber optic light transmission incorporated,
distal: color code: red
18 8590 GF Fiber Optic Light Carrier, for distal illumination, working length 14 cm,
for use with Laryngoscopes 8588 BV, 8590 A-JN, 8590 T, 8590 JV/TV
12067 B and Diverticuloscopes 12067 A, 12068 A
8575 K Laryngoscope Holder and Chest Support, GTTINGEN model,
Spread: max. 65, including:
min. 7
Laryngoscope Holder, GTTINGEN model, with adjustment wheel
Support Rod, movable, with metal ring, diameter 9 cm, length 34 cm
or
8575 KC BENJAMIN-PARSONS Laryngoscope Holder and Chest Support,
including:
Laryngoscope Holder GOETTINGEN model, with adjustment wheel
BENJAMIN-PARSONS Support Rod, movable, with metal ring,
diameter 12 cm and 2 lateral set screws, length 34 cm
26 Endoscopic Surgery of Zenkers Diverticulum

LBECK Chest Support

for Laryngoscope Holders

Special features:
 Moveable plate for chest supports 8575|K/KC,  Ideal for children and overweight patients
8574 KT/KW  Support plate with lateral ring for attaching
 Swivel holding arm tongue spatula 743910 744405
 Fine gear system complements height for adenoidectomy and tonsillectomy
adjustment of chest support
 Ensures safe mounting of the chest
support|and|the laryngoscope

8585 S

8585 S Chest Support, LBECK model,

with gear system for height adjustment and swivel arm
with movable plate, for use with Laryngoscope Chest
Supports 8575 K/KC, 8574 KT/KW, can be mounted on
OR table equipped with standard sliding rail 25 x 10 mm
Endoscopic Surgery of Zenkers Diverticulum 27

Instruments for Diverticuloscopes

12067 TL

12067 TL Clip Forceps

for Diverticuloscopy,
applicator for absorbable
ligating clips,
jaw curved to left,
with cleaning connector,
working length 30 cm,
for use with Clips 12067 TT

12067 TR Same, jaw curved to right

12067 W

12067 W Grasping Forceps, alligator,

with 1 x 2 teeth,
double action jaws,
sheath with suction
channel to remove vapor,
handle with ratchet to
arrest jaw parts,
working length 30 cm
28 Endoscopic Surgery of Zenkers Diverticulum

Instruments for Diverticuloscopes

12067 ML/MR

12067 ML FEHLAND Needle Holder, with ratchet,

jaws size 3.0 mm x 5.8 mm, angled 90 to the left,
working length 30 cm, sheath diameter 4.0 mm

12067 MR Same, angled 90 to the right

12067 R

12067 P

12067 R Suction Tube, insulated, ball end,

outer diameter 2.5|mm, working length 30|cm
12067 S Same, outer diameter 3|mm

12067 P STEINER Insulated Cannula, for suction/coagulation,

with ergonomic handle, fitting for unipolar coagulation,
with cleaning stylet 12067 PM, working length 30 cm,
outer diameter 3.5 mm

Please note:
Simultaneous use of insulated instruments and LASER is prohibited.
Endoscopic Surgery of Zenkers Diverticulum 29

Instruments for Diverticuloscopes

Size 5 mm

Multiple puncture approach Single puncture approach

Operating|instruments, length 30 and 36 cm, Operating|instruments,|length 43 cm, for use with
for|use with trocars size 6 mm operating laparoscopes with inbuilt working channel

37270 SC

Distal Tip Instrument No. Description Size Length

37270 SC 30 cm
Coagulating and Dissecting
37370 SC 5 mm 36 cm
Electrode, with suction channel
37470 SC 43 cm
37270 DB Coagulating and Dissecting 30 cm
37370 DB Electrode, with suction channel, 5 mm 36 cm
37470 DB blunt spatula 43 cm
37270 DL Coagulating and Dissecting 30 cm
37370 DL Electrode, with suction channel, 5 mm 36 cm
37470 DL L-shaped 43 cm

CUSCHIERI Dissecting Suction

37370 DH 5 mm 36 cm
Tube, with suction channel

Coagulating and Dissecting

37370 DU Electrode, with suction channel, 5 mm 36 cm
U-shaped

37270 DX MANGESHIKAR Coagulating and 30 cm

37370 DX Dissecting Electrode, with irrigation 5 mm 36 cm
37470 DX channel, barrel-shaped 43 cm
37270 DV MANGESHIKAR Coagulating and 30 cm
37370 DV Dissecting Electrode, with irrigation 5 mm 36 cm
37470 DV channel, ball end 43 cm

30804 Handle with Trumpet Valve,

for suction or irrigation, autoclavable,
for use with 5 mm coagulating suction tubes
and 5 mm suction and irrigation tubes

Please note:
Simultaneous use of insulated instruments and LASER is prohibited.
30
IMAGE 1 SPIES Camera System n
Economical and future-proof
 Modular concept for flexible, rigid and
3D endoscopy as well as new technologies
 Forward and backward compatibility with video
endoscopes and FULL HD camera heads
Innovative Design
 Dashboard: Complete overview with intuitive
menu guidance
 Live menu: User-friendly and customizable
 Intelligent icons: Graphic representation changes
when settings of connected devices or the entire
system are adjusted
Dashboard
Intelligent icons
Endoscopic Surgery of Zenkers Diverticulum
 Sustainable investment
 Compatible with all light sources
 Automatic light source control
 SPIES VIEW: Parallel display of standard image
and the SPIES mode
 Multiple source control: IMAGE 1 SPIES allows
the simultaneous display, processing and
documentation of image information from
two connected image sources, e.g., for hybrid
operations
Live menu
SPIES VIEW: Parallel display of standard image and SPIES mode
Endoscopic Surgery of Zenkers Diverticulum 31

IMAGE 1 SPIES Camera System n

Brilliant Imaging
 Clear and razor-sharp endoscopic images in  Reflection is minimized
FULL HD  Three SPIES technologies for homogeneous
 Natural color rendition illumination, contrast enhancement and color
shifting

FULL HD image SPIES CLARA

FULL HD image SPIES CHROMA

FULL HD image SPIES SPECTRA A

FULL HD image SPIES SPECTRA B

32 Endoscopic Surgery of Zenkers Diverticulum

IMAGE 1 SPIES Camera System n

TC 200EN

TC 200EN* IMAGE 1 CONNECT, connect module, for use with up to

3 link modules, resolution 1920 x 1080 pixels, with integrated
KARL STORZ-SCB and digital Image Processing Module,
power supply 100 120 VAC/200 240 VAC, 50/60 Hz
including:
Mains Cord, length 300 cm
DVI-D Connecting Cable, length 300 cm
SCB Connecting Cable, length 100 cm
USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US
* Available in the following languages: DE, ES, FR, IT, PT, RU
Specifications:
HD video outputs - 2x DVI-D Power supply 100 120 VAC/200 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1|kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE 1 SPIES

IMAGE 1|CONNECT Module TC 200EN

TC 300

TC 300 IMAGE 1 H3-LINK, link module, for use with

IMAGE 1 FULL HD three-chip camera heads,
power supply 100 120 VAC/200 240 VAC, 50/60 Hz,
for use with IMAGE 1 CONNECT TC 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm
Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes TH 100, TH 101, TH 102, TH|103,|TH|104, TH 106
(fully SPIES-compatible)

22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3,
22 2200 54-3, 22 2200 85-3
(compatible without SPIES function)
LINK video outputs 1x
Power supply 100 120 VAC/200 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg
Endoscopic Surgery of Zenkers Diverticulum 33

HD Imaging with Operating Microscopes

Direct Adaption

Direct adaption to the VARIO operating

microscope from Carl Zeiss Meditec

With the operating microscope the surgeon always has a perfect view of the
operating field. Assistents, OR nurses and students, however, often experience
poor video presentation, especially if FULL HD visualization is not available.
KARL STORZ offers a one-stop-shop solution to upgrade any surgical
microscope with state-of-the-art FULL HD imaging technology.
To achieve optimal results, all components in the video chain from the camera
system to the monitor must be of the highest quality.
The most straightforward and professional connection between camera and
microscope is|the so-called direct adaption.
Here the H3-M COVIEW microscope camera and the corresponding
QUINTUS TV adaptor are directly connected to the microscope via the
C-MOUNT connection.
34 Endoscopic Surgery of Zenkers Diverticulum

IMAGE 1 SPIES Camera Heads n

For use with IMAGE 1 SPIES Camera System

IMAGE 1|CONNECT Module TC 200EN, IMAGE 1 H3-LINK Module TC 300
and with all IMAGE 1 HUB HD Camera Control Units

TH 106

TH 106 IMAGE 1 H3-M COVIEW SPIES Three-Chip FULL HD

Camera Head, 50/60 Hz, SPIES compatible, progressive scan,
with C-MOUNT thread for coupling to microscopes,
2 freely programmable camera head buttons,
with detachable camera head cable, length 900 cm,
for use with IMAGE 1 SPIES and IMAGE 1 HUB HD/HD

20 2001 31

20 2001 31 Keypad, for H3-M camera head, for convenient control of the
most important H3-M camera functions, with PS/2 connector,
cable length 1 m, alternative to a standard keyboard, for use
with H3-M or H3-M COVIEW camera heads, only compatible
with IMAGE 1 HUB HD, not compatible with IMAGE 1 SPIES

Specifications:
IMAGE 1 SPIES FULL HD Camera Heads H3-M COVIEW SPIES
Product code TH 106
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 45 x 50 x 60 mm
Weight 240 g
Optical interface C-MOUNT connection
Min. sensitivity F 1.9/1.4 Lux
Grip mechanism C-MOUNT connection
Cable detachable
Cable length 900 cm
Endoscopic Surgery of Zenkers Diverticulum 35

HD Imaging with Operating Microscope

System Components

QUINTUS High-Performance TV Adaptor for Operating Microscopes

Unleash the full performance of your operating microscope from CARL ZEISS MEDITEC with FULL HD imaging
solutions from KARL STORZ.

The new QUINTUS TV adaptor is the perfect interface The innovative features of QUINTUS are easy to use,
between the operating microscope and the H3-M making it one of the most flexible TV adaptors on the
COVIEW FULL HD microscope camera head from market.
KARL STORZ.

Product Features:
O A rotating C-MOUNT connection at the QUINTUS
TV adaptor allows immediate adaption of the
camera orientation during mounting.
O The focus control makes it possible to easily
achieve parfocality (perfectly sharp camera and
microscope images).
O The iris control provides convenient and optimal
adjustment of the depth of field.
O Pan (X) function enables adjustment of the
horizontal position of the camera image.
O Tilt (Y) function enables adjustment of the vertical
position of the camera image. The pan and tilt
functions helps the surgeon to adjust the position of
the camera image according to his individual needs.
O The QUINTUS ZOOM model also features a
variable focal length f = 43 86 mm. This allows
the surgeon greater flexibility in choosing the
exact zone required for documentation.

Focal length of the QUINTUS TV adaptor:

The QUINTUS TV adaptor is available in the fixed focal lengths f = 45 and f = 55 mm or as a zoom model with
variable focal length 43 86 mm. This provides an optimal FULL HD image in 16:9 in conjunction with the H3-M
COVIEW HD microscope camera head from KARL STORZ.

45 mm 43 86 mm
55 mm

Focal lengths: H3-M COVIEW camera image detail sing a Variable focal length: Adjustable H3-M COVIEW camera
QUINTUS TV adaptor with the fixed focal lengths of 45 and image detail using a QUINTUS zoom adaptor with variable
55 mm. focal length of 43 86 mm.
36 Endoscopic Surgery of Zenkers Diverticulum

HD Imaging with Operating Microscope

System Components

QUINTUS TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with fixed focal length

20 9230 45 QUINTUS Z 45 TV Adaptor, for CARL ZEISS MEDITEC

operating microscopes, f = 45 mm, recommended for
IMAGE 1 HD H3-M/H3-M COVIEW camera heads
20 9230 55 QUINTUS Z 55 TV Adaptor, for CARL ZEISS MEDITEC
operating microscopes, f = 55 mm, recommended for
IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well
as|IMAGE 1 S1 and|S3 camera heads
20 9230 45/20 9230 55

QUINTUS Zoom TV Adaptor for operating microscopes from CARL ZEISS MEDITEC with variable focal length

20 9230 00 Z QUINTUS Zoom TV Adaptor, for CARL ZEISS MEDITEC

operating microscopes, with variable focal length f = 43 86 mm,
for use with all KARL STORZ cameras (SD and HD)

20 9230 00 Z

Further accessories for operating microscopes from CARL ZEISS MEDITEC

20 9250 00 Iris, for ZEISS Pentero, iris as a necessary

extension between the QUINTUS TV adaptor
and the operating microscope ZEISS Pentero

20 9250 00

301513 Optical Beamsplitter 50/50, for|use|with ZEISS

operating microscope or colposcope

301513

Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Mller-Wedel)
are available directly from the manufacturers.
Endoscopic Surgery of Zenkers Diverticulum 37

HD Imaging with Operating Microscope

System Components

QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with fixed focal length

20 9330 45 QUINTUS L 45 TV Adaptor, for LEICA Microsystems

operating microscopes, f = 45 mm, recommended for
H3-M microscope camera head
20 9330 55 QUINTUS L 55 TV Adaptor, for LEICA Microsystems
operating microscopes, f = 55 mm, recommended for
IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z as well
as S1 and S3 camera heads
20 9330 45/20 9330 55

QUINTUS TV Adaptor for operating microscopes from LEICA Microsystems with variable focal length

20 9330 00 Z QUINTUS Zoom TV Adaptor, for LEICA Microsystems

operating microscopes, with variable focal length f = 43 86 mm,
for use with all KARL STORZ cameras (SD and HD)

20 9330 00 Z

QUINTUS TV Adaptor for operating microscopes from Mller-Wedel with fixed focal length

20 9530 45 QUINTUS M 45 TV Adaptor, for Mller-Wedel

operating microscopes, f = 45 mm, recommended for
IMAGE 1 HD H3-M/H3-M COVIEW camera heads

20 9530 55 QUINTUS M 55 TV Adaptor, for Mller-Wedel

operating microscopes, f|=|55|mm, recommended for
IMAGE 1 HD H3-M/H3-M COVIEW, H3, H3-Z and S1,
20 9530 45/20 9530 55 S3 camera heads

Note: Optical beamsplitters for other operating microscopes (i.e. LEICA or Mller-Wedel)
are available directly from the manufacturers.
38 Endoscopic Surgery of Zenkers Diverticulum

IMAGE 1 SPIES Camera Heads n

For use with IMAGE 1 SPIES camera system

IMAGE 1|CONNECT Module TC 200EN, IMAGE 1 H3-LINK Module TC 300
and with all IMAGE 1 HUB HD Camera Control Units

TH 100 IMAGE 1 H3-Z SPIES Three-Chip FULL HD Camera Head,

50/60 Hz, SPIES compatible, progressive scan, soakable,
gas- and plasma-sterilizable, with integrated Parfocal Zoom
Lens, focal length f = 15 31 mm (2x), 2 freely programmable
camera head buttons, for use with IMAGE 1 SPIES
TH 100 and IMAGE 1 HUB HD/HD

Specifications:
IMAGE 1 FULL HD Camera Heads H3-Z SPIES
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 1531 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

TH 104 IMAGE 1 H3-ZA SPIES Three-Chip FULL HD Camera Head,

50/60 Hz, SPIES compatible, autoclavable, progressive scan,
soakable, gas- and plasma-sterilizable, with integrated
Parfocal Zoom Lens, focal length f = 15 31 mm (2x),
2 freely programmable camera head buttons, for use with
TH 104 IMAGE 1 SPIES and IMAGE 1 HUB HD/HD

Specifications:
IMAGE 1 FULL HD Camera Heads H3-ZA SPIES
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 1531 mm
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
Endoscopic Surgery of Zenkers Diverticulum 39

Monitors

9619 NB 19" HD Monitor,

color systems PAL/NTSC, max. screen
resolution 1280 x 1024, image format 4:3,
power supply 100 240 VAC, 50/60 Hz,
wall-mounted with VESA 100 adaption,
including:
External 24 VDC Power Supply
Mains Cord

9619 NB

9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image format 16:9,
power supply 100 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord

9826 NB

9627 NB 27" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image format 16:9,
power supply 85 265 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord
9627 NB-2 Same, with double video inputs

9627 NB/NB-2
40 Endoscopic Surgery of Zenkers Diverticulum

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26" 27"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB 9627 NB 9627 NB-2
Inputs:
DVI-D O O O OO
Fibre Optic optional optional
3G-SDI O optional
RGBS (VGA) O O O OO
S-Video O O O OO
Composite/FBAS O O O OO
Outputs:
DVI-D O O O O
S-Video O O O
Composite/FBAS O O O O
RGBS (VGA) O
3G-SDI O optional
Signal Format Display:
4:3 O O O O
5:4 O O O O
16:9 O O O O
Picture-in-Picture O O O O
PAL/NTSC compatible O O O O

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for 96xx monitor series

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26" 27"
Desktop with pedestal optional optional optional
Product no. 9619 NB 9826 NB 9627 NB/NB-2
Brightness 200 cd/m2 (type) 500 cd/m2 (type) 240 cd/m2 (type)
Max. viewing angle 178 vertical 178 vertical 178 vertical
Pixel distance 0.29 mm 0.3 mm 0.3 mm
Reaction time 5 ms 8 ms 12 ms
Contrast ratio 700:1 1400:1 3000:1
Mount 100 mm VESA 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg 9.8 kg
Rated power 28 W 72 W 45 W
Operating conditions 040C 535C 535C
Storage -2060C -2060C -2060C
Rel. humidity max. 85% max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm 776 x 443 x 114 mm
Power supply 100240 VAC 100240 VAC 85265 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC, MDD93/42/EEC,
protection class IPX2 protection class IPX2
Endoscopic Surgery of Zenkers Diverticulum 41

Cold Light Fountains and Accessories

495 NL Fiber Optic Light Cable,

with straight connector,
diameter 3.5 mm, length 180 cm
495 NA Same, length 230 cm

Cold Light Fountain XENON 300 SCB

20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated
KARL STORZ Communication Bus System SCB
power supply:
100 125 VAC/220 240 VAC, 50/60 Hz
including:
Mains Cord
SCB Connecting Cable, length 100 cm
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt

Cold Light Fountain XENON NOVA 300

20 134001 Cold Light Fountain XENON NOVA 300,

power supply:
100125 VCA/220240 VAC, 50/60 Hz
including:
Mains Cord
20 1330 28 XENON Spare Lamp, only,
300 watt, 15 volt
42 Endoscopic Surgery of Zenkers Diverticulum

Data Management and Documentation

KARL STORZ AIDA Exceptional documentation

The name AIDA stands for the comprehensive implementation

of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.

WD 200-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

WD 250-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL|HD, 2D/3D,
including SMARTSCREEN (touch|screen),
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

*XX Please indicate the relevant country code

(DE, EN, ES, FR, IT, PT, RU) when placing your order.
Endoscopic Surgery of Zenkers Diverticulum 43

Workflow-oriented use

Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
All important patient information is just a click away.

Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.

Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.

Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.

Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.

Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
44 Endoscopic Surgery of Zenkers Diverticulum

Equipment Cart

UG 220 Equipment Cart

wide, high, rides on 4 antistatic dual wheels
equipped with locking brakes 3 shelves,
mains switch on top cover,
central beam with integrated electrical subdistributors
with 12 sockets, holder for power supplies,
potential earth connectors and cable winding
on the outside,
Dimensions:
Equipment cart: 830 x 1474 x 730 mm (w x h x d),
shelf: 630 x 510 mm (w x d),
caster diameter: 150 mm
inluding:
Base module equipment cart, wide
Cover equipment, equipment cart wide
Beam package equipment, equipment cart high
3x Shelf, wide
Drawer unit with lock, wide
2x Equipment rail, long
Camera holder
UG 220

UG 540 Monitor Swifel Arm,

height and side adjustable,
can be turned to the left or the right side,
swivel range 180, overhang 780 mm,
overhang from centre 1170 mm,
load capacity max. 15 kg,
with monitor fixation VESA 5/100,
for usage with equipment carts UG xxx

UG 540
Endoscopic Surgery of Zenkers Diverticulum 45

Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer,

200 V 240 V; 2000 VA with 3 special mains socket,
expulsion fuses, 3 grounding plugs,
dimensions: 330 x 90 x 495 mm (w x h x d),
for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor,

200 V 240 V, for mounting at equipment cart,
control panel dimensions: 44 x 80 x 29 mm (w x h x d),
for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm,

height adjustable, inclinable,
mountable on left or right,
turning radius approx. 320, overhang 530 mm,
load capacity max. 15 kg,
monitor fixation VESA 75/100,
for usage with equipment carts UG xxx

UG 510
46 Endoscopic Surgery of Zenkers Diverticulum

Notes:
 WITH COMPLIMENTS OF
KARL STORZ ENDOSKOPE