Steps in Laparoscopic Heller's Cardiomyotomy: Pars Flaccida Approach

After the ports have been inserted, the patient is usually placed in a steep reverse Trendelenburg position. A 10-mm 30° angled camera is used.

The initial approach involves dividing the left phrenoesophageal and phrenogastric ligaments, allowing exposure of the left crus. Next,  the gastric fundus is mobilized to create a tension-free fundoplication. After the left phrenoesophageal ligament is divided, the gastrohepatic ligament is incised. The right and anterior phrenoesophageal ligament and peritoneum overlying the anterior abdominal esophagus are divided, with care taken not to damage the underlying anterior vagus nerve. A posterior esophageal window is created. During this step, the posterior vagus nerve should be visualized and protected. Adequate mediastinal esophageal mobilization is crucial for a long esophageal myotomy and tension-free fundoplication. A Penrose drain may be placed around the EGJ and used to retract the esophagus caudally and laterally during hiatal and mediastinal mobilization. To clear a path for the myotomy across the EGJ, it is useful to resect the cardioesophageal fat pad to the left of the anterior vagus nerve while simultaneously mobilizing the vagus from the esophagus. This allows a straight plane for performance of the myotomy. 

During the myotomy, electrocautery should be avoided unless absolutely necessary. Individual muscle fibers are divided by hooking them and applying gentle upward traction. Bleeding from the muscle or submucosa is controlled with pressure and time. These steps are important to avoid delayed perforation from unrecognized thermal mucosal injury.

Progressive division of the longitudinal and then the circular muscle layer is performed as the myotomy is carried superiorly, 6-8 cm above the EGJ. Once the circular muscles are divided, a mucosal plane is reached with smooth, white, bulging mucosa (see the image below). Thus, the entire myotomy spans approximately 6-10 cm (3 cm below to 6-8 cm above the EGJ). The most difficult dissection involves the 3-cm myotomy on the stomach, where the plane of dissection becomes blurred with intervening sling muscular fibers and the underlying gastric mucosa is thinner, increasing the risk of perforation.