Laparoscopic Heller procedure for achalasia

This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons. Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.

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Laparoscopic   Heller   procedure   for   achalasia

Authors
B Dallemagne, J Marescaux
Abstract
This is a 'live' surgery performed by Dr. B Dallemagne demonstrating the key steps in performing a Heller procedure. Minimal dissection is carried out to expose the anterior surface of the esophagus, after which the myotomy is delicately performed with scissors. This video is recommended to upper GI surgeons.
Barium swallow showed the classic sign of achalasia at the level of the cardia in this elderly woman with gastroesophageal reflux disease. CT-scan of the chest showed a large sigmoid-like esophagus. Mobilization of the esophagus begins with the authors opening only the anterior aspect of the hiatus to gain access to the esophagus. They dissect the upper part of the esophagus and expose the azygos vein on the right, clearing the gastroesophageal junction on the gastric side of the cardia. They continue by opening the hypertrophic musculature to enable swallowing, then continue with a Heller myotomy.
Keywords
myotomy, esophagus, Heller procedure, anterior mobilization of esophagus
Media type
Duration
11'50''
Publication
2007-10
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2182.htm

Laparoscopic   Heller   procedure   for   achalasia

3. Heller myotomy 04'06''
You see we have dissected the vagus trunk here and now we are going to start the myotomy. So the idea for the myotomy is to have the access for the esophagus ready. This is the esophagus. So I will start on the esophageal side of the cardia, because usually it’s a little bit easier. With normal scissors I know that it can bleed, but I don’t care because I don’t want to make injuries to the mucosa. You see that the mucosa is already there, and I’m opening with blunt scissors without any cautery. Initially I want to know where my plane is. There are still esophageal fibers here. This is the muscle and this is the mucosa, and I know that I have a plane between the muscle and the mucosa. You see the mucosa in white, so I have the right plane. Here is the mucosa and here is the muscle. If I do that with the active blade on the mucosa, I will get some injury. I will make some burning of the mucosa and have a postoperative leak. If you are using this kind of technology, you will have to do this way with the active blade on the external side of the esophagus and the non-active blade on the mucosa.The problem now is that we have to work within the chest and create the plane with scissors, because the ultrasonic device is too tough to do that. Here I am in the plane that I have created. I open a little bit the vagus trunk and I can divide. Note that this patient is old and therefore very fragile, I have some problems getting up, and we go within the mediastinum. You see that in the mediastinum because the anatomy in this woman, I don’t have a very clear view, so I will change the optical system and move from a zero degree to a 30 degree to be sure that I’m right inside. But on the other hand, I’m pleased with this myotomy within the chest, which is probably sufficient in this woman. Now we are continuing on the gastric side of the cardia. We clearly see the mucosa up there. You can imagine that there are still some fibers there going down on the gastric side of the cardia. So we have to clear this as well. But I have to go back. I know that I can find my plane quite well here but to go back is very difficult. So I’m continuing either with scissors or the hook, but here I use the hook, which allows you to go back. You see that it’s a little bit easier. You see that there are still fibers there. I’m on the gastric side of the cardia. This is the esophagus and here is the stomach. And usually when you have a perforation, it’s usually within this area because the fibers are very adherent to the mucosa, so we have to do it very carefully fibers by fibers to be sure that we don’t get any injury. Do you do an intraoperative endoscopy or not? Personally I’m not doing it any longer, but I would recommend to do it when you start with this operation. I’m opening these fibers and you can see that there are still some outlet problems. Can you show us the inferior limit of the dissection? You see this is the fundus, the angle of His is here. If I’m stopping the dissection here, I will have probably the 2cm on the gastric side of the cardia. In this patient, it is essential to make it quite clear because the only thing that we want for her is to allow her to eat and avoid this regurgitation. What about the upper landmark for the myotomy in the chest. Usually it’s about 6cm. You see we have already made almost 6cm on the esophageal side. My lower limit will be there. When I start the dissection of the cardia, usually you have a vein that is crossing this area on the fat pad. This is usually this vein which makes the transition between the esophagus and the gastric part of the cardia. You see this small vein and this is a characteristic of the gastric side. The anterior vagus trunk is on the right side of the esophagus. You’ve seen that I didn’t dissect the posterior aspect of the esophageal attachments, so probably I keep on with some antireflux mechanism. You don’t do any anterior protection as the Dor procedure? No, I don’t. What about the follow-up of the patient after the procedure? The patient will have a swallow tomorrow morning to be sure that we don’t have any leak on the myotomy, and then she will be on soft food during 2 weeks, and then she will progressively be allowed to drink and eat what she wants. I want to be sure that I did a perfect opening of the cardia and thus have no problem.