Laparoscopic Heller Myotomy and Partial Fundoplication for Achalasia

1. Positioning

1. After a rapid sequence intubation, a nasogastric tube and a urinary Foley catheter are placed.
2. The patient is then positioned supine, propped with surgical beanbag to allow the patient to be placed in a steep reverse Trendelemburg.
3. The legs are placed in the semilithotomy position on stirrups. The surgeon usually stands between the patient’s legs and the assistant on patient’s right side.

2. Exposure and Surgical Approach

4. Trocar Placement
   • Anatomical landmarks such as the xiphoid process and bilateral costal margins are marked prior to insufflation. A 1-cm transverse incision at the midline, two-finger breadths superior to umbilicus, is made for placement of Veress needle and abdomen insufflation.
   • Once the abdomen is insufflated to a pressure of 15 mmHg, the optical trocar is placed to accommodate a 10-mm 30-degree laparoscope.
   • Two operating trocars (11 mm each) are placed 2–3 cm below the right and left costal margins at the level of the midclavicular line.
   • A 5-mm incision is made immediately to the left of the xiphoid process for placement of a Nathanson retractor. The retractor is positioned to expose the gastroesophageal (GE) junction by mobilizing the hepatic left lobe laterally and superiorly.
   • Another 11-mm trocar is placed at the level of the left anterior axillary line and the transverse umbilical line.
   • After all ports are positioned, the patient is placed in steep reverse Trendelenburg position that allows an optimal exposure of the GE junction by allowing all organs to fall downwards.
5. Identification and Division of Gastrohepatic Ligament
   • Control and divide accessory left hepatic artery if present.
6. Separation of Right Crus of Diaphragm from Esophagus
   • Identify posterior vagus nerve.
7. Excision of Esophageal Fat Pad
   • Dissection started just proximal to first branch of left gastric artery.
8. Division of Peritoneum and Phreno-Esophageal Membrane
   • Identify anterior vagus nerve.
9. Dissection of Left Crus of Diaphragm to Junction with Right Crus
10. Division of Short Gastric Vessels
11. Mobilization of Esophagus within Mediastinum
    • The gastrohepatic ligament is divided to expose the right pillar of the crus. An Allis clamp is placed at the GE junction to allow lateral traction and facilitate the blunt dissection of the esophagus from the right crus.
    • An accessory left hepatic artery may be encountered at this point and safely transected.
    • The esophageal fat pad, in the anterior abdominal esophagus, is transected to expose the angle of His, which will provide exposure needed for the cardiomyotomy.

3. Therapeutic Intervention - Esophageal Myotomy

12. Cardiomyotomy consists of dividing the longitudinal and circular muscle fibers until outpouching of the submucosa is seen, with care not to perforate the submucosa. This dissection can be accomplished with the hook cautery.
13. The dissection starts at the GE junction where the anatomical landmarks of the longitudinal and circular muscle fibers are most consistent, and extended cranially for about 7 cm.
14. Then the myotomy is extended downward 3 cm onto the stomach up to the first branch of the left gastric artery. The gastric extension of the myotomy is often the most difficult part of the operation, because it entails in dividing the clasp (or U) fibers first described by Lieberman-Maffert.¹⁰ 
15. The anterior and posterior vagus nerves are identified and preserved throughout the dissection, frequently reassessing their course in the stomach wall.
16. The cardiomyotomy is performed onto the right anterolateral aspect of the esophagus, at the 10-o’clock position, between the anterior and posterior vagal nerves.
17. It is started proximal to the GE junction and extended 6 cm proximally and 2.5–3.0 cm distally onto gastric wall.
18. Muscles edges are separated by blunt dissection to expose mucosa.

4. Dor Funduplication

19. Although a Toupet fundoplication is a good alternative, we prefer to perform a Dor fundoplication as studies have shown similar outcomes. Hence, the fundus is freed by taking down the short gastric arteries using the access from the left upper quadrant.
20. Then a left row of sutures is placed that encompasses the anterior wall of the stomach and the left edge of the myotomy. The uppermost stitch includes the apex of the left pillar of the crus.
21. Next, the gastric fundus is folded over the myotomy and sutured superiorly along the diaphragmatic hiatus and medially along the right edge of the myotomy with 2-0 silk interrupted sutures. This completes the 180-degree Dor fundoplication.
22. Left suture row:
    • 1st suture incorporates fundus, left esophageal wall, and left crus.
    • Other two sutures incorporate fundus and left esophageal wall.
    • Fundus of stomach folded to expose mucosa.
23. Right suture row:
    • Three sutures incorporate fundus and right crus.
    • Two more sutures incorporate fundus and esophageal hiatus.

5. Closure of Wound

24. Evaluate for Perforation of Myotomy
25. Removal of Trocars

6. Postoperative Care

26. Immediate care: before extubation, the Foley and nasogastric tube are removed.
27. Postoperative day 1, the patient is given a regular diet.
28. Imaging of choice is a water-soluble contrast medium swallow radiography if there are concerns for esophageal perforation; otherwise, no imaging is usually needed.
29. Postoperative follow up is done 1 week after discharge.
30. Screening: this operation does not remove the risk of esophageal squamous-cell carcinoma (SCC) or gastroesophageal reflux resulting in development of adenocarcinoma. Therefore, upper endoscopic screening every 3–4 years is usually recommended. Recurrent dysphagia merits upper endoscopy evaluation to rule out malignancy.
31. Patient seen in clinic two weeks after discharge.