Heller Myotomy and Posterior Partial Fundoplication
Fig. 7.1
Division of gastrohepatic ligament
Fig. 7.2
Division of phrenoesophageal membrane
Fig. 7.3
Circumferential exposure of the esophagus
Fig. 7.4
Division of short-gastric vessels
Before creating the fundic wrap, the GEJ fat pad is reflected or resected (Fig. 7.5), and then a longitudinal seromuscular incision is made starting either just below or just above the GE junction. Longitudinal and circumferential muscle fibers are divided until mucosa is visualized. The myotomy is extended 6 cm above the GEJ and 2–3 cm distally onto the stomach (Fig. 7.6a, b), taking precautions to avoid the anterior vagus nerve. One possible risk of Heller myotomy is mucosal perforation. Patients previously treated for achalasia, by either pneumatic dilation or botulinum toxin, are at greater risk. Intraoperative injuries are repaired immediately with absorbable sutures, usually without additional morbidity. Many surgeons routinely assess mucosal integrity at the completion of the myotomy by instillation of methylene blue or air. If a perforation is repaired, usually a Dor fundoplication is chosen as the stomach will cover the area of repair.
Fig. 7.5
Exposure of the gastroesophageal junction
Fig. 7.6
(a) Starting the myotomy ; (b) 6 cm myotomy
The diaphragmatic crura are then reapproximated posterior to the esophagus. Then, the gastric fundus is passed through the retroesophageal window, and a ~240-degree partial posterior hemifundoplication is fashioned with the fundus anchored to the cut edges of the esophageal muscle to help maintain their separation.
Conclusions
The body of scientific evidence supports use of a partial fundoplication after Heller myotomy for patients with achalasia. The literature fails to show any significant difference between partial anterior and posterior fundoplication. In the absence of further large randomized controlled trials, the decision of performing an anterior or a posterior wrap is based on the surgeon’s experience and preference [29].
Conflict of Interest
The authors have no conflict of interest to declare.
