Heller's Myotomy

Principles
Laparoscopic
- anterior longitudinal myotomy
- and some variant of partial fundo to prevent free reflux.

Prep
Keep pt on liquid diet for 3d
Careful prevention of aspiration on induction

Method
1. Position with steep reverse Trendelenberg.
2. 10mm 15cm below xiphoid to left of midline.
2. Retract liver.
3. 4mm and 10mm in RUQ and LUQ as 2 working ports, and a 5mm for assistant in left abdo.
5. Open phrenoesophageal membrane
6. Excise gastroesophageal fat pad to expose GEJ.
- identify and preserve anterior vagal trunk.
7. Dissect out anterior oesophagus; don't go posterior.
8. Myotomy
- split longitudinal fibres and divide circular with harmonic scalpel (or scissors).
- avoid much electrocautery to prevent going too deep.
- enter submucosal plane, carry proximally 5-6cm from the GEJ and distally 2-3cm onto anterior gastric wall.
- separate muscle edges for 50% of circumference.
--> distinctive bulging view of the mucosa.
9. Endoscopy to rule out perforation and show obstruction is cleared.
- if perforation, repair with lap interrupted 5-0 monofilament absorbable sutures and gentle knots.
10. Dor fundo (anterior 180-200o)
- buttresses mucosal repair.
- after mobilization, top of cardia is sutured to left crural pillar and L side of myotomy (at superior aspect) with nonabsorbable.
- suture placed to anchor fundus to right of myotomy to incorporate right crural pillar.
- suture to join fundus with inferior aspect of R side of myotomy.
[OR Toupet Wrap (probably better ground)
- i.e. posterior 270o]

Length of myotomy?
Extended myotomy probably better (3cm vs 1-2cm)
- on basis of less dysphagia and reintervention rates.

Reflux?
Major complication, 60% have pH studies positive
Hence the fundo.
- reduces time of pH exposure, maintains good emptying of oesophagus.
Heller or Toupet fine
Nissen not -- dysphagia much more common with total 360 wrap

Treat angulated / tortuous 'sigmoid' shape?
No need, just do the same operation.

Outcomes
85% or more have good outcomes and symptom resolution.
- patients with lower LES pressures (<35 mm Hg) are much more likely to get relief from surgery.
6.3% complications
- triple risk (9% vs 3%) if previous balloon dilation or botox, and double rate of recurrence.
--> thus some say should reserve endoscopic therapy for poor candidates.