case so treated the pouch
was blown out again during a fit of sneezing eight months after
operation. (3) Plication of the walls of the sac by catgut sutures, as
in the Matas obliterative operation for aneurysm. (4) Freeing and
removing the sac, with suture of the esophageal wound. (5) Removal of
the sac by a two-stage operation, in which method the initial step is
the deliverance of the sac into the cervical wound, where it remains
surrounded by gauze packing until adhesions have walled off the
mediastinum. The work is completed by cutting off the sac and either
suturing the esophageal wound or touching it with the cautery, and
allowing it to heal by granulation. External exposure and amputation
of the sac has been more frequently done than any other operation.
Unless the pouch is large, it is extremely difficult to find after the
surgeon has exposed the esophagus, for the reasons that at operation
it is empty and that when the adhesions about it are removed the walls
of the sac contract. After removal, the sac is disappointingly small
as compared with its previous size in the roentgenogram, which shows
it distended with opaque material. It has been the chagrin of skilled
surgeons to find the diverticulum present functionally and
roentgenographically precisely the same as before the performance of
the very trying and difficult operation. The time of operation may be
shortened at least by one-half by the aid of the esophagoscopist in
the Gaub-Jackson operation. Intratracheally insufflated ether is the
anesthesia of choice. After the surgeon has exposed the esophagus by
dissection, the endoscopist introduces the esophagoscope into the sac,
and delivers it into the wound, while the surgeon frees it from
adhesions. The esophagoscope is now withdrawn from the pouch and
entered into the esophagus proper, below the diverticulum, while the
surgeon cuts off the hernial sac and sutures the esophagopharyngeal
wound over the esophagoscope. The presence of the esophagoscope
prevents too tight suture and possible narrowing of the lumen (Fig.
102).

[FIG. 102.--Schematic representation of esophagoscopic aid in the
excision of a diverticulum in the Gaub-Jackson operation. At A the
esophagoscope is represented in the bottom of the pouch after the
surgeon has cut down to where he can feel the esophagoscope. Then the
esophagoscopist causes the pouch to protrude as shown by the dotted
line at B. After the surgeon has dissected the sac en