This is similar to Nissen fundoplication.

It is preferable to perform a circumferential esophageal dissection to perform a Heller myotomy, similar to a Nissen (see Chapter 6 ). This allows placement of a Penrose drain around the gastroesophageal junction to provide downward traction during the proximal extension of the myotomy. We also routinely divide the short gastric vessels during this dissection as we feel it is necessary when performing a Toupet or Dor fundoplication at the end of the procedure.

Identification of the vagal nerve prior to performing the myotomy is important to avoid inadvertent transection. After identifying the vagal nerve it is encircled with a 0-silk suture. The two tails are clipped together, and the vagus nerve is bluntly dissected off the esophagus for the length of the myotomy. During the myotomy, the surgeon can control the path of the vagus nerve by grasping and retracting the prior placed sutures. If a large esophageal fat pad is encountered, it should be resected.

In order to avoid excessive bleeding during the myotomy, a dilute solution of epinephrine can be injected into the esophageal wall with a long, 22-gauge spinal needle. The surgeon should stabilize the tip of this needle with a grasper, insure injection into the muscular plane, and avoid intraluminal injection.