Overview
Definition:
Laparoscopic Heller myotomy is a minimally invasive surgical procedure performed to treat achalasia cardia
It involves incising the lower esophageal sphincter (LES) and a portion of the esophageal muscle to relieve the obstruction and improve swallowing
It is often combined with a partial fundoplication (e.g., Dor or Toupet) to prevent gastroesophageal reflux
This technique offers advantages over open surgery in terms of reduced pain, shorter hospital stays, and faster recovery.
Epidemiology:
Achalasia cardia is a rare esophageal motility disorder with an estimated incidence of 1 in 100,000 people
It can occur at any age, but it is more commonly diagnosed in individuals between 30 and 60 years old
There is no significant gender predilection
The prevalence varies geographically, but it is considered a globally occurring condition.
Clinical Significance:
Achalasia cardia significantly impacts a patient's quality of life due to progressive dysphagia, regurgitation, chest pain, and weight loss
Untreated achalasia can lead to malnutrition, aspiration pneumonia, and an increased risk of esophageal cancer (squamous cell carcinoma)
Laparoscopic Heller myotomy is the gold standard surgical treatment, providing lasting symptom relief for a majority of patients and improving their functional status and well-being
Understanding this procedure is crucial for surgical residents preparing for DNB and NEET SS examinations.
Indications
Patient Selection:
Patients with a confirmed diagnosis of achalasia cardia who have failed or are intolerant to medical management (e.g., pneumatic dilation, botulinum toxin injection)
Primary surgical indication for severe or progressive symptoms
Evaluation of esophageal function (manometry) is essential for diagnosis and guiding treatment.
Disease Severity:
All stages of achalasia (I-IV) as per the Chicago classification, although earlier intervention may yield better long-term outcomes
Consideration for sigmoid esophagus (stage IV) may require different approaches or adjuncts.
Contraindications:
Absolute contraindications include severe comorbidities that make general anesthesia unsafe
Relative contraindications include prior extensive upper abdominal surgery, significant hiatal hernia repair, or severe esophageal stricture that might preclude effective myotomy
Inadequate esophageal length for myotomy.
Preoperative Preparation
Diagnostic Workup:
Esophageal manometry to confirm diagnosis and classify achalasia type (Type I, II, III)
Upper endoscopy to rule out pseudoachalasia or malignancy and assess for complications like inflammation or strictures
Barium swallow to assess the degree of dilation and tortuosity of the esophagus
Chest X-ray and routine blood investigations.
Patient Counseling:
Detailed discussion of the procedure, potential benefits, risks, and expected outcomes
Explanation of the minimally invasive approach, recovery process, and dietary modifications post-operatively
Informed consent is mandatory.
Medications:
Continuation of essential medications
Discontinuation of anticoagulants and antiplatelet agents as per surgical protocol
Prophylactic antibiotics are typically administered before induction of anesthesia.
Procedure Steps
Patient Positioning And Access:
Patient is placed in the lithotomy position
Four to five laparoscopic ports are inserted: umbilical for the camera, and other quadrants for instruments (graspers, dissector, scissors)
Pneumoperitoneum is established with CO2.
Esophageal Dissection:
The gastroesophageal junction is identified
The phrenoesophageal membrane is dissected, and the peritoneum is opened to expose the distal esophagus
The anterior vagus nerve is identified and preserved
Dissection proceeds proximally along the esophagus for a sufficient length (typically 5-7 cm).
Myotomy Creation:
A longitudinal myotomy is performed through the muscular layers of the esophagus, extending from the distal esophagus, including the LES, and continuing onto the stomach for about 1-2 cm
The mucosa should bulge into the myotomy but remain intact
Care is taken to avoid perforating the esophageal mucosa
Electrocoagulation is used to control bleeding from muscle vessels.
Fundoplication And Closure:
A partial anterior (Dor) or posterior (Toupet) fundoplication is performed over the myotomy to help prevent reflux
The fundoplication helps to buttress the myotomy and reduce the risk of GERD
The port sites are then closed, and the pneumoperitoneum is released
The integrity of the esophageal mucosa is usually confirmed intraoperatively with methylene blue dye or air insufflation.
Intraoperative Checks:
Confirmation of complete LES division without significant mucosal injury
Adequate length of myotomy
Secure and appropriately placed fundoplication
Hemostasis is meticulously ensured
Evaluation for any unexpected findings or complications.
Postoperative Care
Pain Management:
Intravenous analgesics (opioids, NSAIDs) are used initially, transitioning to oral medications as tolerated
Patient-controlled analgesia (PCA) may be employed
Adequate pain control is essential for early mobilization and recovery.
Dietary Advancement:
Initially, patients are kept nil per os (NPO)
Once bowel sounds return and pain is controlled, a clear liquid diet is initiated, gradually advancing to soft, then regular food as tolerated
Patients are instructed to eat slowly and chew food thoroughly to avoid dysphagia.
Monitoring And Ambulation:
Vital signs are closely monitored
Patients are encouraged to ambulate early to prevent deep vein thrombosis and promote gastrointestinal motility
Nasogastric tube, if placed, is removed early
Chest physiotherapy may be advised.
Discharge Criteria:
Patient is able to tolerate oral intake, ambulate independently, has adequate pain control with oral analgesics, and is free from significant complications
A follow-up appointment is scheduled
Instructions on diet, activity, and warning signs are provided.
Complications
Early Complications:
Bleeding from muscle vessels or during dissection
Esophageal perforation or mucosal tear, potentially leading to mediastinitis or sepsis
Pneumothorax or hemothorax from diaphragmatic or pleural injury
Injury to adjacent organs (e.g., spleen, vagus nerve)
Anastomotic leak (if fundoplication is performed).
Late Complications:
Gastroesophageal reflux disease (GERD) is the most common long-term complication, particularly if fundoplication is inadequate or absent
Recurrent dysphagia due to incomplete myotomy, scarring, or esophageal stricture formation
Inadequate weight gain
Long-term dependence on acid-suppressive therapy.
Prevention Strategies:
Meticulous surgical technique, including careful dissection, identifying and preserving vital structures, and ensuring complete LES division
Intraoperative confirmation of mucosal integrity
Appropriate choice and technique of fundoplication
Careful dietary advancement postoperatively
Close follow-up to detect and manage GERD or recurrent dysphagia.
Prognosis
Factors Affecting Prognosis:
Success rates are generally high, with significant improvement in dysphagia and regurgitation in 80-95% of patients
Factors influencing outcome include the type of achalasia (Type III tends to have a slightly lower success rate), the surgeon's experience, completeness of the myotomy, and the technique of fundoplication
Early diagnosis and treatment are associated with better outcomes.
Outcomes:
Most patients experience substantial and lasting relief of symptoms, leading to improved quality of life and weight gain
Long-term success rates remain high for many years post-operatively
However, a small percentage of patients may require re-operation or continued medical management for residual or recurrent symptoms.
Follow Up:
Regular follow-up is recommended to monitor for symptom recurrence, dysphagia, or development of GERD
Endoscopic evaluation may be indicated if symptoms are concerning for stricture or malignancy
Patients are typically advised to maintain a healthy diet and lifestyle
Long-term surveillance for esophageal cancer is important for patients with long-standing achalasia.
Key Points
Exam Focus:
Laparoscopic Heller myotomy is the surgical treatment of choice for achalasia cardia
Key steps include myotomy and fundoplication
Complications include perforation, bleeding, and GERD
Manometry is crucial for diagnosis and classification.
Clinical Pearls:
Always confirm mucosal integrity after myotomy
Choose a fundoplication technique (Dor or Toupet) that suits the individual patient and surgeon preference
Aggressive acid suppression may be required post-operatively in some patients
Emphasize slow eating and thorough chewing to prevent post-myotomy dysphagia.
Common Mistakes:
Incomplete myotomy leading to recurrent symptoms
Esophageal perforation without timely recognition and management
Inadequate fundoplication leading to severe GERD
Neglecting to rule out pseudoachalasia due to malignancy
Underestimating the importance of post-operative dietary modifications.