Laparoscopic Heller myotomy for achalasia

What are the basic components of laparoscopic Heller myotomy for achalasia? 

Surgical treatment of achalasia consists of a longitudinal myotomy of the distal esophagus and gastroesophageal (GE) junction, first described by Ernest Heller in 1913. Most myotomies were performed through the chest before the advent of minimally invasive surgery. The transabdominal laparoscopic approach is currently the procedure of choice with good long-term results in 84% to 94% of patients. 

Five trocars are placed in the upper abdomen in an arrangement similar to that of a laparoscopic antireflux operation. A myotomy roughly 6 to 8 cm in length is performed, 3 cm below the GE junction. The myotomy is carried down to the level of the mucosa. Intraoperative manometry is then used to confirm successful ablation of the pathologic high-pressure zone. A partial fundoplication is performed after the completion of the myotomy around a 52-Fr bougie. There is a general consensus that a complete 360-degree wrap may cause significant obstruction at the distal end of the esophagus and lead to worsening of esophageal function in patients with already impaired peristalsis. The Toupet fundoplication (partial posterior wrap) and Dor fundoplication (partial anterior wrap) are equally popular among surgeons. With the addition of a Dor antireflux wrap, the incidence of gastroesophageal reflux disease (GERD) decreases from 47.6% to 9.1%. A randomized trial compared Heller myotomy and Dor fundoplication with Heller myotomy and Nissen fundoplication; the recurrence rate in the Nissen group was significantly higher than the Dor group (15% vs. 2.8%, respectively) supporting the addition of Dor fundoplication to the Heller myotomy as the preferred method to prevent GERD. Patients with mild to moderate reflux after addition of a potential fundoplication can be easily managed medically.


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