Mastering Heller Myotomy: Preserving the Anterior Vagus Nerve During Laparoscopic Heller Myotomy

During Heller myotomy, preservation of the anterior vagus nerve is a critical step that directly impacts postoperative gastric function. The anterior vagus nerve runs along the anterior surface of the distal esophagus and continues onto the stomach, where it contributes significantly to gastric motility and pyloric function. Because it is often thinner and more delicate than the posterior trunk, it is particularly vulnerable during esophageal mobilization and gastric extension of the myotomy. Careful identification before initiating the anterior dissection is essential to prevent inadvertent traction, thermal injury, or transection. Gentle blunt dissection combined with minimal use of energy devices near the nerve helps ensure its integrity. Surgeons must remain constantly aware of its course, especially when extending the myotomy 2–3 cm onto the gastric wall. Injury to the anterior vagus nerve may result in delayed gastric emptying and postoperative dysmotility. Therefore, meticulous technique and deliberate nerve preservation are fundamental components of a successful laparoscopic Heller myotomy.