Laparoscopic Heller Myotomy for Type II Achalasia

Oscar M. Crespin, MD; Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD

Disclosures

March 26, 2013

Type III Achalasia vs Esophageal Spasm

Image C is the upper gastrointestinal series of a patient who presented with chest pain, whose manometry showed a pattern of type III achalasia (spastic contractions). This is clinically is similar to patients with esophageal spasm.

In type III achalasia, there is aperistalsis and impaired relaxation of the LES. In diffuse esophageal spasm, there are often some intact peristaltic contractions and 2 or more simultaneous contractions with relaxation of the LES (Figure 9).

Figure 9a. Type III achalasia. 9b. Diffuse esophageal spasm.

Operative Technique

Video Clip: Surgery for Achalasia

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Preparation and Visualization

Patient position. Patients are placed in a supine, split-leg, or lithotomy position with padding, such as a surgical bean bag. We prefer the lithotomy position for optimal ergonomics and access to the hiatus. The patient is positioned in a steep reverse Trendelenburg position, which allows the stomach and other organs to fall away from the esophageal hiatus.

Abdominal access and port placement. Abdominal access is obtained at the left upper quadrant just inferior to the costal margin. Pneumoperitoneum is established according to standard laparoscopic techniques. Four operative ports (2 for the surgeon, 1 for the assistant, and 1 for the scope) are then placed under direct visualization, and liver retraction is then achieved by any number of such devices on the market.

Mobilization of the gastric fundus. Begin on the left side by first dividing the phrenogastric ligament and exposing the left crus. The short gastric vessels to the fundus are divided with a sealing device. The gastrohepatic ligament is incised in an avascular plane. After the esophagus is exposed, the GEJ fat pad is undermined, as is the anterior vagus nerve. This allows a long gastric myotomy to be performed and carried across the GEJ to the esophagus. A posterior esophageal window is created to perform a posterior partial (Toupet) fundoplication. In performing this window, the posterior vagus nerve is identified and protected.

Mobilization of the mediastinal esophagus. The distal portion of the mediastinal esophagus is mobilized to achieve sufficient length to perform a myotomy incision that divides the entire length of the LES and permits a tension-free fundoplication. A Penrose drain is placed around the GEJ to retract the esophagus laterally and inferiorly.

Myotomy and Fundoplication

Myotomy. We use a 50-French lighted bougie as a platform to perform gastric myotomy close to the lesser curvature to the stomach, measuring 3 cm to the GEJ and extended upward 6 cm above the GEJ. The anterior surface of the esophagus is completely exposed, and slight tension is created by retracting caudally with a Babcock retractor or similar instrument over the bougie.

We prefer starting on the stomach. Although this is a more difficult submucosal plane to identify, we find it easier to proceed in a cephalad than caudal direction. The use of electrocautery should be avoided unless it is critical when creating the myotomy. If bleeding occurs, it should be controlled with pressure and patience, because thermal injury can lead to unrecognized trauma to or perforation of the esophagus.

The myotomy is performed by individually dividing the esophageal and gastric muscle fibers. The longitudinal muscles are divided first, which exposes the underlying circular muscles. Division of the circular layer reveals a bulging mucosal plane that should appear smooth and white. Endoscopic inspection of the mucosa and the myotomy are done proceeding to the next steps to identify and repair any mucosal perforations.

Fundoplication. A 270° posterior fundoplication is constructed with the posterior aspect of the gastric fundus, which is passed through the retroesophageal window and secured to the right edge of the myotomy and right crus of the diaphragm with a coronal suture. Another interrupted suture is placed to secure the posterior fundus to the base of the right crus. The leading posterior edge of the fundus is secured to the right edge of the myotomy with interrupted sutures. Any redundancy of the fundus is removed from behind the esophagus, and the proximal, anterior aspect of the fundus is secured to the left side in a similar fashion. If there is a hiatal hernia, the crura can be opposed with posterior sutures without making the hiatus snug.[3,4,5,6]

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