Where is the Target Endpoint of the Myotomy in Heller Myotomy

The pars flaccida of the gastrohepatic ligament is divided using a monopolar, bipolar, or ultrasonic energy device.Then creation of the Retroesophageal Window andplacing the Penrose drain allows retraction of the distal esophagus which facilitates exposure of the anterior esophagus where the myotomy is created.The myotomy is best started on the esophageal side where the muscle fibers are more predictable in their orientation. Once the proximal extent is reached the myotomy is typically walked down on to the stomach 2-3 cm caudal to the GEJ.Various techniques can be applied to then separate the muscles from the deeper mucosa .The target endpoint of the myotomy will become apparent as the esophageal muscle thins out. In general, an esophageal myotomy of 6cm and usually more is required. Most surgeons carry the myotomy as far proximal as the exposure will allow.  In type III achalasia especially, the longer the myotomy the better (> 8-cm).After adequate division of the esophageal muscle, attention is then directed to the gastric cardia. The gastroesophageal fat pad may need to be excised to visualize the area around the cardia. The desired length and direction of the gastric myotomy is carefully marked. The remainder of the gastric myotomy is then performed in a similar fashion to the esophageal myotomy with spreading of the longitudinal muscle fibers and division of the deeper muscle layers.