Adequate Heller Myotomy

Laparoscopy video case: five trocars were placed in the upper part of the abdomen. The gastroesophageal junction and lower mediastinal esophagus were widely mobilized while both vagus nerves were preserved. The short gastric vessels were not routinely divided. No bougie was used in all cases. A myotomy to the level of submucosa was started on the anterior esophageal wall nearly 1-1.5 cm above EGJ. At this site moscular adhisions to mucosa is looser. Myotomy was extended 6 to 8 cm proximal to EGJ on the anterior esophageal wall upward and downward to gastric cardia, 2-3 cm below the gastroesophageal junction. Adequacy of the myotomy was assessed by noting mucosal bulging without any visible crossing fibers and by performing endoscopy if indicated. Both crura were loosely approximated anterior to the esophagus, and a 180° anterior Dor fundoplication was completed by suturing the wrapped fundus to the right and left crura. A closed suction drain was placed adjacent to the myotomy, and a water-soluble contrast study was performed before the drain was removed and oral feeding was started the following day.