Conventional Laparoscopic vs. Laparo-Endoscopic Single Site (LESS) Heller Myotomy: Is Less More?

Sharona B Ross, MD, Darrell J Downs, ATC, Janelle Spence, BS, Mark Giorgi, Christian B Rodriquez, BS, Indraneil Mukherjee, MD, Alexander S Rosemurgy, MD. Florida Hospital Tampa

Introduction: Laparoscopic Heller myotomy is a first-line treatment for patients with achalasia. The evolution of laparoscopy has allowed laparoscopic Heller myotomy to be undertaken through a single 12mm umbilical incision, Laparo-Endoscopic Single-Site (LESS) surgery. Because it is a “scarless” approach, LESS surgery has the potential to significantly improve cosmetic outcome and patient satisfaction after myotomy. This study was undertaken to compare a single institution’s experience with conventional laparoscopic vs. LESS Heller myotomy.

Methods: With IRB approval, 635 patients have been prospectively followed since 1991 after Heller myotomy; we compared outcomes after conventional laparoscopic vs. LESS myotomy, excluding 45 patients undergoing esophageal diverticulectomy. Patients scored the frequency and severity of their symptoms before and after myotomy using a Likert scale (0=never/not bothersome to 10=always/very bothersome). Patients were queried before myotomy about their greatest postoperative priorities and after myotomy about their scar satisfaction (1=revolting to 10=beautiful). Data are presented as median or median (mean ±SD), where appropriate.

Results: 432 patients underwent conventional laparoscopic myotomy and, more recently, 158 consecutive patients underwent LESS myotomy. 52% of patients were men; median age was 49 years and BMI was 24 kg/m2 for all patients.  Prior to Heller myotomy, patients noted many frequent and severe symptoms (Table). Before LESS myotomy, patients scored safety as their greatest priority, with the appearance and size of the scar and postoperative pain following thereafter. Heller myotomy ameliorated the frequency and severity of symptoms (Table). Relative to conventional laparoscopy, patients who underwent LESS myotomy had similar symptom amelioration without developing new symptoms (e.g., heartburn) (Table), but had a shorter hospital LOS at 1 (2 days ± 3.0) vs. 1 (3 days ± 7) (p<0.05). Median scar satisfaction for patients undergoing LESS myotomy was 10. Patient satisfaction after conventional laparoscopic and LESS Heller myotomy was at 84%.

Conclusions: Heller myotomy, regardless of approach, provides efficacious, satisfactory, and durable palliation of achalasia; symptom resolution and patient satisfaction support its continued application. The LESS approach provides the same salutary benefits as the conventional laparoscopic approach with the additional benefits of shorter hospitalization and improved cosmesis through outstanding scar satisfaction. Ultimately, there is “more gain” associated with LESS Heller myotomy than there is with conventional laparoscopic Heller myotomy, thereby promoting its application.