Heller Myotomy with Partial (Dor) Fundoplication

Fig. 6.1

Position of the patient. (Reprinted with permission © Springer Nature [6])

Trocar Placement

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 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°. These ports are used for the insertion of graspers, scissors, and dissecting and suturing instruments (Fig. 6.2).

../images/473262_1_En_6_Chapter/473262_1_En_6_Fig2_HTML.jpg — Fig. 6.2

Position of trocars for laparoscopic Heller myotomy

Key Note

Care must be taken not 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).

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. We begin the dissection above the caudate lobe of the liver and continue 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.

Key Note

An accessory left hepatic artery originating from the left gastric artery can be encountered, which can be usually safely divided. The electrocautery should be used with caution next to the right pillar of the crus because the lateral spread of the current may injure the posterior vagus nerve.

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 will be performed.

Key Note

Care must be taken not to damage the anterior vagus nerve or the esophageal wall. For this reason, the nerve should be left attached to the esophageal wall, and the peritoneum and the phrenoesophageal membranes should be lifted from the esophageal wall by blunt dissection before they are divided.

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 (Fig. 6.3).