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Laparoscopic Heller Myotomy

Laparoscopic Heller myotomy is a minimally invasive procedure that opens the tight lower esophageal sphincter (the valve between the esophagus and the stomach) by performing a myotomy (cutting the thick muscle of the lower part of the esophagus and the upper part of the stomach) to relieve the dysphagia (difficulty swallowing). Further, a Dor fundoplication (a partial wrapping of the stomach around the esophagus to make a low-pressure valve) is performed to prevent reflux from the stomach into the esophagus following the myotomy. There is a very small chance that patients may develop reflux despite Dor fundoplication and may need to be treated with antacid medication. This procedure results in a great symptomatic relief.

The steps of the operation are the following:

Five small incisions are made in the abdomen to allow insertion of a camera and working surgical instruments, as shown in the images below.

Incisions for Laparoscopic Myotomy
& Dor Fundoplication

Larparoscopic Myotomy 2

For the myotomy (cutting the muscle), the lower part of the esophagus and the upper part of the stomach are exposed and marked to accurately identify the location of the lower esophageal sphincter, as shown below.

Larparoscopic Myotomy 4

The myotomy includes cutting of the muscular layer of the lower part of the esophagus and the upper part of the stomach (see images below) to completely open the lower esophageal sphincter and relieve dysphagia.

Larparoscopic Myotomy 6

To prevent reflux from the stomach into the esophagus, a Dor fundoplication is performed by partially wrapping the stomach around the esophagus. The fundoplication covers the myotomy and makes a low pressure valve, as shown below.

Larparoscopic Myotomy 8

Video: Laparoscopic Heller Myotomy

Patients stay in the hospital for one night. They start drinking one day after surgery and are discharged home. They will follow dietary restrictions for about two weeks and can start advancing their diet after a clinic visit two weeks following the surgery. This procedure is routinely performed at the Memorial Hermann Southeast Esophageal Disease Center for the treatment of patients with achalasia.

References

1. Lyass S, Thoman D, Steiner JP, et al. Current status of an antirefluxprocedure in laparoscopic Heller myotomy. Surg Endosc. 2003;17:554 –558.

2. Richards WO, Torquati A, Holzman MD, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240:405– 412; discussion 412–415.

3. Zaninotto G, Annese V, Costantini M, et al. Randomized controlled trial of botulinum toxin versus laparoscopic Heller myotomy for esophageal achalasia. Ann Surg. 2004;239: 364 –370.

4. Ruffato A, Mattioli S, Lugaresi ML, et al. Long-term results after Heller-Dor operation for oesophageal achalasia. Eur J Cardiothorac Surg. 2006;29: 914–919.

5. Endoscopic and Surgical Treatments for Achalasia, A Systematic Review and Meta-Analysis, Guilherme M. Campos, MD, PhD, Eric Vittinghoff, PhD, Charlotte Rabl, MD, Mark Takata, MD, Michael Gadenstatter, MD, Feng Lin, MS, and Ruxandra Ciovica, MD, Ann Surg, Volume 249, Number 1, January 2009:45-57

By Farzaneh Banki, M.D.