Retro-Esophageal Tunneling and Myotomy by Stretching Muscles in Achalasia

After incision of the phrenoesophageal ligament, the dissection is performed selectively over the anterior aspect of the esophagus. The anterior and posterior vagus nerves are identified and their branches preserved. The short gastric vessels are not divided and the esophagus is encircled, in order to full lengh myotomy. The esophageal dissection is prolonged into the mediastinum, 6-8 cm above the gastroesophageal junction. The esophagomyotomy is then extended proximally to the GEJ for about 6-8 cm and distally for 2-3 cm below the cardia on the gastric wall. We found advantageous and safe performing the myotomy by stretching and tearing the circular muscle fibers with two laparoscopic graspers directed in opposite direction. Once the submucosal plane is reached, the muscular layer is separated bluntly from the submucosa and the stretching myotomy is easily extended proximally and distally. Bleeding from the esophageal musculature is minimal and no attempt is made to diathermy the bleeding.