Symposium
Laparoscopic Heller Myotomy for Achalasia Technical Aspects FRANCISCO SCHLOTTMANN, M.D.,* MARCO E. ALLAIX, M.D.,† MARCO G. PATTI, M.D.*‡
From the *Department of Surgery, University of North Carolina, Chapel Hill, North Carolina; †Department of Surgical Sciences, University of Torino, Torino, Italy; and ‡Department of Medicine, University of North Carolina, Chapel Hill, North Carolina Esophageal achalasia is a primary esophageal motility disorder defined by the lack of esophageal peristalsis, and by a lower esophageal sphincter that fails to relax in response to swallowing. Patients’ symptoms include dysphagia, regurgitation, aspiration, heartburn, and chest pain. Achalasia is a chronic condition without cure, and treatment options are aimed at providing symptomatic relief, improving esophageal emptying, and preventing the development of megaesophagus. Presently, a laparoscopic Heller myotomy with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a laparoscopic Heller myotomy.
A a primary esophageal motility disorder characterized by the absence of E esophageal peristalsis and failure of the lower esophSOPHAGEAL
CHALASIA IS
ageal sphincter (LES) to relax in response to swallowing. This disease is rare, with an incidence of about 1 in 100,000 individuals. Achalasia occurs with equal frequency in men and women and in white and nonwhite people, but incidence increases with age. In most studies, the mean age at diagnosis is over 50 years.1 The disease is characterized by a functional loss of inhibitory neurons of the esophageal myenteric plexus in the distal esophagus and LES, which are needed for peristalsis of the smooth muscle of the esophageal body and relaxation of the tonic LES.2 Dysphagia, regurgitation, heartburn, and chest pain are the most frequent symptoms in achalasia patients. There are no curative therapies for achalasia. Most treatments are directed at reducing contractility in the LES to allow for adequate esophageal emptying. Presently, a laparoscopic Heller myotomy (LHM) with a partial fundoplication is considered the best treatment modality. A properly executed operation is key for the success of a LHM. LHM: Technical Elements
After induction of general endotracheal anesthesia, the patient is positioned supine in low lithotomy position Address correspondence and reprint requests to Francisco Schlottmann, M.D., University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC 27599-7081. E-mail:
[email protected].
with the lower extremities extended on stirrups, with knees flexed 20 to 30 degrees. To avoid sliding due to the steep reverse Trendelenburg position used during the entire procedure, a bean bag is inflated to create a “saddle” under the perineum. Pneumatic compression stockings are always used as prophylaxis against deep vein thrombosis (particularly important because the increased abdominal pressure secondary to the pneumoperitoneum and the steep Trendelenburg position decrease venous return). The surgeon stands between the patient’s legs, and the first and second assistants on the right and left side of the operating table, respectively. Step 1: Placement of Ports
Five 10-mm ports are used for the procedure. The first port is placed about 14 cm below the xiphoid process; it can be also placed slightly (2–3 cm) to the left of the midline to be in line with the hiatus. This port is used for insertion of the scope. The second port is placed in the left midclavicular line at the same level of port 1, and it is used for the insertion of a Babcock clamp for traction and the instrument used to take down the short gastric vessels. The third port is placed in the right midclavicular line at the same level of the other two ports, and it is used for the liver retractor. The fourth and fifth ports are placed under the right and left costal margins so that their axes and the camera form an angle of about 120 degrees. These ports are used for the insertion of graspers, scissors, and dissecting and suturing instruments (Fig. 1).
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Troubleshooting
A common mistake is to place the trocars too low. This can make the operation more challenging (e.g. difficult to take down the more proximal short gastric vessels or inability to reach the gastroesophageal junction with the Babcock). Step 2: Division of Gastrohepatic Ligament and Identification of Right Crus of the Diaphragm and Posterior Vagus Nerve
After the left segment of the liver is retracted and the gastroesophageal junction is exposed, the gastrohepatic ligament is divided. The dissection begins above the caudate lobe of the liver and continues proximally until the right crus is identified. The crus is then separated from the esophagus by blunt dissection and the posterior vagus nerve is identified.
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of a vessel not completely sealed. Damage of the gastric wall can be caused by the grasping instruments or by a burn from the electrocautery. Step 5: Esophageal Myotomy
It is important to remove the fat pad to expose the gastroesophageal junction. A Babcock clamp is then applied over the junction, and the esophagus is pulled downward and to the left to expose the right side of the esophagus. The myotomy is performed at the 11 o’ clock position and is started about 3 cm above the gastroesophageal junction by reaching the proper submucosal plane. The myotomy is then extended proximally for about 6 cm above the esophagogastric junction, and distally for about 2.5 cm onto the gastric wall. Thus, the total length of the myotomy is typically
Troubleshooting
An accessory left hepatic artery originating from the left gastric artery can be encountered. If this vessel creates problems of exposure it can be divided. The electrocautery should be used with caution next to the right pillar of the crus because the lateral spread of the current may injury the posterior vagus nerve. Step 3: Division of Peritoneum and Phrenoesophageal Membrane above the Esophagus and Identification of the Left Crus of the Diaphragm and Anterior Vagus Nerve
The peritoneum and the phrenoesophageal membrane above the esophagus are divided and the anterior vagus nerve is identified. The left pillar of the crus is separated from the esophagus. Dissection is limited to the anterior and lateral aspects of the esophagus, and no posterior dissection is needed if a Dor fundoplication is planned.
FIG. 1.
Position of trocars for laparoscopic Heller myotomy.
FIG. 2.
Heller myotomy.
Troubleshooting
Care must be taken not to damage the anterior vagus nerve or the esophageal wall. To this end, the nerve should be left attached to the esophageal wall, and the peritoneum and the phrenoesophageal membrane should be lifted from the wall by blunt dissection before they are divided. Step 4: Division of Short Gastric Vessels
The short gastric vessels are taken down all the way to the left pillar of the crus, starting from a point midway along the greater curvature of the stomach. Troubleshooting
Bleeding from the gastric vessels or the spleen is usually caused by excessive traction or by transection
No. 4
HELLER MYOTOMY TECHNIQUE
about 8 cm (Fig. 2). Extending the myotomy downward on the gastric side remains a crucial part of the procedure to deal thoroughly with the unrelaxing LES.3, 4 Troubleshooting
The myotomy should not be started close to the esophagogastric junction, because at this level the layers are often poorly defined, particularly if prior dilations or botulinum toxin injections have been performed. Once the submucosal plane is reached about 3 cm above the esophagogastric junction, it is easier to extend the myotomy proximally and distally. There are many instruments that can be used to perform the myotomy. We prefer an electrocautery with a 90-degree hook because it allows careful lifting and division of the circular fibers. If bleeding occurs from the cut muscle fibers, gentle compression is preferred to electrocautery. Any perforation should be repaired using a fine absorbable suture material (4-0 or 5-0). Step 6: Dor Fundoplication
The Dor fundoplication (180 degrees anterior) has two rows of sutures, one left and one right. The left row comprises three stitches: the uppermost stitch
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incorporates the fundus of the stomach, the esophageal wall, and the left pillar of the crus (Fig. 3A); the other two incorporate the stomach and the esophageal wall (Fig. 3B). The gastric fundus is then folded over the exposed mucosa, so that the greater curvature is next to the right pillar of the crus. The second row of stitches comprises three stitches between the fundus and the right pillar of the crus, and two additional stitches between the superior aspect of the fundoplication and the rim of the esophageal hiatus (Fig. 3C). These last stitches remove any tension from the second row of sutures. The decision between a Dor fundoplication (180 degrees anterior) and a Toupet fundoplication (270 degrees posterior) is usually based on surgeon’s preference. The advantages of a Dor fundoplication are that it does not require posterior dissection (avoiding a possible injury to the posterior vagus nerve), and covers the exposed esophageal mucosa. The advantages of a Toupet fundoplication are that it keeps the edges of the myotomy separated, and theoretically may provide better reflux control. Two randomized controlled trials tried to identify which fundoplication was most beneficial for patients, and found no significant difference in the control of symptoms and similar postoperative reflux profiles with both types of fundoplication.5, 6
FIG. 3. Dor fundoplication. (A) First stitch. (B) Left row of stitches. (C) Right row of stitches.
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Troubleshooting
The fundoplication must be constructed without any tension. For this reason it is important to take down the short gastric vessels, and to use only the fundus of the stomach. Conclusions
A LHM is an effective and long lasting treatment for patients with achalasia. Its success will rely on a properly executed operation that respects the key technical elements. REFERENCES
1. Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014;383:83–93.
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2. Goyal RK, Chaudhury A. Pathogenesis of achalasia: lessons from mutant mice. Gastroenterology 2010;139:1086–90. 3. Mattioli S, Pilotti V, Felice V, et al. Intraoperative study on the relationship between the lower esophageal sphincter pressure and the muscular components of the gastro-esophageal junction in achalasic patients. Ann Surg 1993;218:635–9. 4. Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg 2003;138: 490–5. 5. Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomizedcontrolled trial. Surg Endosc 2012;26:18–26. 6. Kumagai K, Kjellin A, Tsai JA, et al. Toupet versus Dor as a procedure to prevent reflux after cardiomyotomy for achalasia: results of a randomised clinical trial. Int J Surg 2014;12: 673–80.
