Technique of myotomy in laparoscopic Heller procedure

This is the case of a 60-year-old woman with a chief complaint of dysphagia for solids and liquids, regurgitation, and chest pain. An initial diagnosis of achalasia was made in 2007 with the manometry showing a high hypertonic low esophageal sphincter which failed to relax and respond to swallowing. Upper GI series showed a severe dilatation of the esophagus and narrowing at the gastroesophageal junction. An endoscopic dilatation was attempted, but failed. Decision was made to perform a laparoscopic Heller myotomy together with a Dor fundoplication.

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Technique   of   myotomy   in   laparoscopic   Heller   procedure

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
This is the case of a 60-year-old woman with a chief complaint of dysphagia for solids and liquids, regurgitation, and chest pain. An initial diagnosis of achalasia was made in 2007 with the manometry showing a high hypertonic low esophageal sphincter which failed to relax and respond to swallowing. Upper GI series showed a severe dilatation of the esophagus and narrowing at the gastroesophageal junction. An endoscopic dilatation was attempted, but failed. Decision was made to perform a laparoscopic Heller myotomy together with a Dor fundoplication.
Classification
live recorded
Keywords
Myotomy, laparoscopic Heller procedure
Media type
Duration
12'47''
Publication
2011-06
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jun 2011;11(06).
URL: http://www.websurg.com/doi-vd01en3272.htm

Technique   of   myotomy   in   laparoscopic   Heller   procedure

4. Myotomy 02'07''
Once the esophagogastric junction has been clearly visualized, and the vagus nerve protected, the myotomy is started onto the distal esophagus, just above the gastroesophageal junction, at the 12 o’clock position using scissors. We feel that this is a safer area to start the division of the esophageal muscular layer with easier identification of the mucosa. The mucosal plane is reached using blunt dissection. Care is taken to avoid the use of cautery during this maneuver to prevent a secondary perforation. Careful dissection allows for a good protrusion of the esophageal mucosa. All muscular fibers are divided to ensure completeness of the myotomy. The myotomy is first extended proximally for about 6cm. This patient complained of chest pain together with dysphagia, although a formal diagnosis of vigorous achalasia was not obtained at manometry. In this setting, it is important to prolong the myotomy well onto the esophageal body to relieve any potential cause of esophageal spasm, recurrence, or obstruction. The second step of the procedure consists in extending the myotomy distally onto the esophagogastric junction and the gastric wall. This is an extremely important step of the procedure in that an incomplete myotomy at this level would be responsible for residual or recurrent dysphagia. The extension of the myotomy onto the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus to oblique at the stomach, makes it difficult to develop the necessary mucosal plane, and bleeding is more likely to occur. Also it is probably the most challenging part because it is where the risk of iatrogenic perforation is higher, especially in a patient such as this who underwent previous treatment or dilation. The myotomy is now extended distally for about 2-2.5cm onto the gastric side.