Laparoscopic Heller Myotomy

Achalasia is a functional disorder of the esophagus characterized by loss of coordinated peristalsis and lack of lower esophageal sphincter (LES) relaxation. This is thought to occur from absence of the myenteric neural plexus. The principal presenting symptoms include dysphagia and chest pain. The classic diagnostic presentation is a “bird’s beak” deformity on upper gastrointestinal study. Upper endoscopy and manometry are usually performed in the diagnostic work up, the later indicating a lack of normal peristalsis and incomplete LES relaxation. The treatment options include botulinum, bougie dilation, and laparoscopic Heller myotomy.  Of these, the laparoscopic Heller myotomy offers 77-100% resolution of symptoms at 5 years, and 75% at 15 years. It carrie a 6.3% risk of complications and 0.1% risk of mortality.  Botulism toxon injection is effective to 85% initially, but 30% at one year.  Endoscopic dilation if 15-58% effective at 10 years, but may require multiple dilations. The effect is 13% after the first treatment, and carries a 1-5.6% risk of perforation.

Preoperative preparation

Patients are prepared with deep venous thrombosis prophylaxis with sequential compression stockings and subcutaneous heparin or low-molecular weight heparin.  Prophylactic antibiotics may be given; and foley catherization as well as nasogastric tube decompression are recommended.

All pressure points are padded and the surgeon may either stand between the patient’s legs in a split-leg formation, or on the patient’s left side with the assistant on the right.  Laparoscopic monitors are situated at the head of the bed.

Port placement

An initial trocar can be placed  13-18 cm from from the xyphoid process in the midline, either with an open cut-down technique, pre-insufflation with a Veress needle followed by trocar placement or optical trocar placement, or optical trocar placement alone. Three to four additional ports, 5-12 mm according to the surgeon’s presence can be placed in a number of configuations along the left and right of the abdomen, above the level of the umbilicus, to act as the surgeon’s working ports, an assistant port, and optionally a liver retraction port.

Procedure

Dissecting the esophageal hiatus

A fan, triangle, or other liver retractor elevates the left lobe of the liver to facilitate visulization of the esophageal hiatus.  The gastrohepatic ligament is entered following by dissection of the esophagophrenic ligaments. The anterior vagus nerve should be identified and preserved.

Myotomy

The gastroesophageal junction is identified, and this area can be exposed with caudal retraction on the gastroesophageal fat pad.  A monopolar hook cautery or ultrasonic device is then used to divide the outer, longitudinal muscle fibers of the esophagus on its right anterolateral surface.  Many surgeons will use concomitant upper endoscopy to visualize the high pressure zone during division of the esophageal muscle layer; under this direct visualization, the circular fibers can be divided.  This dissection is taken 2-3 cm onto the stomach carefully.  An airleak test can then be performed.

Partial fundoplication

An anterior, Dor, or posterior, Toupet, fundoplication can be performed as an antireflux procedure following esophagogastric myotomy.  Division of short gastric vessels to facilitate fundoplication is at the discretion of the surgeon.

Postoperative care

A gastrograffin study may be performed on postoperative day number one to rule out a leak and to examine the patency of the gastroesophageal junction.  Alternatively, the patient may be started on a full liquid or mechanical soft diet initially.

References

1. Urbach DR, Hansen PD, Khajanchee YS, Swanstrom LL. A decision analysis of the optimal initial approach to achalasia: laparoscopic Heller myotomy with partial fundoplication, thoracoscopic Heller myotomy, pneumatic dilatation, or botulinum toxin injection.
J Gastrointest Surg. 2001;5(2):192-205.
2. Villegas L, Rege RV, Jones DB. Laparoscopic Heller myotomy with bolstering partial posterior fundoplication for achalasia.
J Laparoendosc Adv Surg Tech. 2003;13(1):1-4.