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Laparoscopic Heller Myotomy

Laparoscopic Heller Myotomy provides similar results to open Heller myotomy for the treatment of oesophageal achalasia with the advantage of quicker recovery.

This operation is specifically for treatment of Achalasia, a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach. This is a condition in which the valve between the oesophagus and stomach (lower Oesophageal sphincter, LOS) is abnormally tight and the pumping action of the Oesophagus itself is abnormal resulting in dysphagia (inability to swallow). In this procedure the muscles of the cardia (lower esophageal sphincter or LES) are cut, allowing food and liquids to pass to the stomach.

Till recently this surgery was performed using an open procedure, either through the chest (thoracotomy) or through the abdomen (laparotomy). However, open procedures involve greater risks and longer recovery times. Modern Heller myotomy is normally performed using minimally invasive laparoscopic techniques, which minimize risks and speed recovery significantly.

Causes of Achalasia

There are primary and secondary causes of this disease. It is felt that patients with primary Achalasia lack a specific nerve complex in the muscular wall of the esophagus that is responsible for relaxation of the LES during meals. Degenerative changes can occur in the entire chain of nerves that begins in the brain and extends through the brain stem, spinal cord, esophagus and stomach. This is confirmed by pathology that has found that there is a loss of ganglion cells in the myenteric plexus (nerve connections that stimulate the esophagus). Another finding is active destruction of the nerve cells by another cell type called 'lymphocytes'. It is not understood why this destruction of the nerve cells occurs.

At any rate, it is this absence of neural impulses that creates a functional lack of control in the esophagus and LES. This lack of nerve stimulation causes the LES to remain tight and unable to relax.

Other disease entities can cause achalasia as well: esophageal cancer, scleroderma and diabetes, among others.


The most frequent presenting symptoms are difficulty swallowing (dysphagia). It is insidious and intermittent in the beginning but tends to become progressively worse. It is rare that it leads to an abrupt loss of ability to eat or drink. The symptoms are subtle in its onset and most describe "fullness".

Heartburn, Coughing and lung infections from food particles trapped in bronchial tubes, regurgitation of undigested foods, Chest spasms or pains, resembling heart pain (angina), Hoarseness, drooling and belching are among the indications that observed.


During the procedure, the patient is put under general anesthesia. Five or six small incisions are made in the abdominal wall and laparoscopic instruments are inserted. The myotomy is a lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way. The esophagus is made of several layers and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner muscosal layer intact.

There is a small risk of perforation during the myotomy. A barium swallow is performed after the surgery to check for leaks. If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.

Food can easily pass downward after the myotomy has cut through the lower esophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial fundoplication to reduce the incidence of postoperative acid reflux. In Dor or anterior fundoplication, which is the most common method, part of the stomach (the fundus) is laid over the front of the esophagus and stitched into place so that whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the esophagus instead. Nissen or complete fundoplication (wrapping the fundus all the way around the esophagus) is generally not considered advisable because peristalsis is absent in achalasia patients.

After laparoscopic surgery, most patients can take clear liquids later the same day, start a soft diet within 2-3 days and return to a normal diet after one month. The typical hospital stay is 2-3 days and many patients can return to work after two weeks. If the surgery is done open instead of laparoscopically, patients may need to take a month off work. Heavy lifting is typically restricted for six weeks or more.

The Heller myotomy is a long-term treatment and many patients do not require any further treatment. However, some will eventually need pneumatic dilation, repeat myotomy (usually performed as an open procedure the second time around), or esophagectomy. It is important to monitor changes in the shape and function of the esophagus with an annual timed barium swallow. Regular endoscopy may also be useful to monitor changes in the tissue of the esophagus, since reflux may damage the esophagus over time, potentially causing the return of dysphagia, or a premalignant condition known as Barrett's esophagus.

Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.


There is a small risk of perforation during the myotomy. A barium swallow is performed after the surgery to check for leaks. If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.


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