Muscle Splitting Technique in Heller's Myotomy for Achalasia Surgery

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General Surgery

Case description

Dissection starts by entering the gastrohepatic ligament, ensuring the hepatic branch of the vagus nerve is preserved. The interface between the right phrenoesophageal ligament and right crus is divided to access the mediastinum, allowing further dissection along the anterior aspect of the crus. Energy devices are used sparingly in this phase, with most dissection from right to left performed bluntly using two atraumatic graspers.A circumferential esophageal dissection is completed with a posterior window created at the base of the crura, through which a Penrose drain is passed and secured around the gastroesophageal junction. The gastroesophageal fat pad is then divided for better exposure of the longitudinal muscle fibers of the lower esophageal sphincter (LES), while the anterior vagus nerve is carefully identified and preserved. The Penrose drain aids in countertraction and exposure of the esophagus's anterior surface, with mediastinal dissection extending as necessary.Three techniques are used to divide the circular muscle fibers effectively: the tip-to-tip muscle-tearing method, where muscle fibers are grasped and controlled fracturing is performed with atraumatic graspers; the laparoscopic vessel sealing device for hemostasis while dissecting and dividing fibers; and hook electrocautery, which involves lifting muscle fibers away from the submucosa while applying short bursts of energy. However, this third technique is least preferred due to the risk of thermal injury to the submucosa.Myotomy begins about 1 cm proximal to the gastroesophageal junction. After splitting the longitudinal muscle fibers, circular fibers are gradually divided using sharp and blunt dissection. Myotomy continues proximally to 5–7 cm from the gastroesophageal junction and extends 2–3 cm onto the gastric cardia, similarly dividing the crossing sling fibers. If type III achalasia is suspected, a longer myotomy may be performed. Endoscopy and transillumination can reveal mucosal defects, and an alternative leak test using methylene blue diluted in saline can identify thinned submucosal areas. If a defect is found, it is primarily repaired with fine absorbable sutures (3-0 or 4-0), often complemented by a Dor fundoplication to support the repair. The procedure concludes with a cardiomyotomy and partial fundoplication, with no significant difference observed in antireflux capacity between Dor and Toupet fundoplications.

 

tags: achalasia Cardiomyotomy Dor fundoplication gastrohepatic ligament Heller heller myotomy surgical anatomy surgical technique surgical video case

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