Laparoscopic Heller Myotomy

Children account for approximately 5% of all patients with alaggia. The Heller esophagocardiomyotomy is the most definitive treatment for this condition. The procedure is well established. The 4 major steps are mobilization of the distal esophagus, a long esophagoyotomy carried onto the stomach as a cardiomyotomy, and finally an anterior fundoplication to cover the myotomy and decrease gastroesophageal reflux. The most critical part of the operation is the myotomy, where mucosal perforations can occur, typically secondary to burns from an energy source, such as hook cautery. This video will demonstrate a myotomy performed in a precise manner without the use of any energy source. The patient is a 14-year-old boy with progressive dysphagia and 30 pound weight loss over 6 months. Contrast studies, manometry, and endoscopy all confirmed the diagnosis of allasia. The trochar sites are similar to those for laparoscopic fun duplication shown here in a different patient. 5 millimeter trochars were used. The esophageal mobilization has been completed. An 8 centimeter silk suture is used to measure the distance from the diaphragm to the cardia. Notice that the posterior attachments of the esophagus to the hiatus are intact. An arthroscopic knife is introduced through the abdominal wall and used to initiate the esophageal myotomy. And the scissors are then used to deepen the myotomy. A right angle grasper spreads the muscle fibers. This can be done in a precise manner. Once the longitudinal muscle is mobilized, traction in opposite directions achieves satisfactory separation without injury to the submucosa. The myotomy proceeds from distal to proximal. The outer longitudinal and inner circular layers are well identified, including individual circular fibers which can be precisely divided by the tip of the instrument. The heel protects the submucosa. The dissection is bloodless. The proximal extent of the esophagus at the diaphragm has been reached. The direction of dissection is then reversed to extend the myotomy onto the gastric cardia. The gastric submucosa can be seen. A few remaining circular fibers on the esophagus are identified and divided. The cardiomyotomy continues for a distance of approximately 2 centimeters. The full extent of the myotomy can be seen. The nasogastric tube is pulled back to the hiatus, and the myotomy is tested by air and sufflation. The final surgical result is shown here with the completed anterior funduplication. The patient had near complete resolution of his symptoms. A postoperative contrast study confirmed resolution of the esophageal obstruction.