Surgical Management of Achalasia: Laparoscopic Heller Myotomy

Abstract

The laparoscopic Heller myotomy is the gold standard therapy for patients with achalasia. All newly diagnosed patients fit to undergo surgery should be considered for this procedure. All patients should have a preoperative medical assessment, and the surgical team should be aware of the risk of aspiration at the time of induction. The procedure begins by mobilizing the entire hiatus, taking care to preserve any accessory left hepatic vessels and vagus nerves. The myotomy is begun 1–2 cm above the GE junction, and the submucosal plane is entered. The muscular fibers are avulsed carefully between graspers for at least 5 cm above the GE junction and 2 cm below. Intraoperative endoscopy is used to confirm adequate length and depth of the myotomy as well as rule out perforation. A partial fundoplication is performed to prevent postoperative reflux. While not a cure for the underlying motility disorder, the Heller myotomy offers excellent long-term relief of dysphagia with >90% patient satisfaction at 10 years after surgery.