Extended Laparoscopic Heller Myotomy for Type III Achalasia A Fiber-by-Fiber Approach

In type III achalasia, characterized by spastic and hypertensive esophageal contractions, an extended and carefully controlled Heller myotomy is essential for durable symptom relief. In this video, I demonstrate a laparoscopic technique based on meticulous separation of the esophageal circular muscle fibers over a length of approximately 6–8 cm, allowing complete disruption of spastic segments. The muscle fibers are individually identified, gently separated, and divided in a controlled manner to preserve mucosal integrity. Distally, the myotomy is extended 2–3 cm onto the gastric wall, where traction and counter-traction are primarily used to split the muscle fibers rather than electrocautery or ligature. This atraumatic approach on the stomach minimizes thermal injury and reduces the risk of mucosal perforation at the esophagogastric junction. Such a tailored, fiber-by-fiber myotomy is particularly advantageous in type III achalasia, where muscle thickness and spasm demand precision rather than speed.