Operative indications

Dysphagia with manometric findings consistent with achalasia is an indication for surgery. Short-term relief can be achieved with endoscopic injection with botulinum toxin (Botox) or pneumatic dilation. These nonoperative interventions carry a small risk for perforation and may result in scarring, which will increase the risk for mucosal injury during surgical myotomy.

Preoperative evaluation, testing, and preparation

Patients with symptoms of dysphagia should be questioned for the severity, frequency, and concurrent presence of heartburn, chest pain, regurgitation, and significant weight loss. Upper gastrointestinal contrast study may show the characteristic tapering of the distal esophagus (bird’s beak deformity). A megaesophagus is indicative of advanced disease and may result in a lower success rate. All patients, especially elderly patients with dysphagia and weight loss, should have an upper endoscopy to evaluate for cancer. Biopsy and further evaluation with endoscopic ultrasound (EUS) should be performed for lesions suspicious for cancer. Esophageal manometry is the gold standard to diagnose achalasia. Manometric findings of tertiary or aperistaltic waveforms, normal to high LES pressures, and high receptive LES pressures are consistent with achalasia. Manometry is especially useful to differentiate achalasia from other esophageal motility disorders such as diffuse esophageal spasm, nutcracker esophagus, and severe GERD. Patients with heartburn who have undergone endoscopic dilation should have a pH study to differentiate pathologic reflux due to dilation from food stasis due to poor esophageal emptying. Nutritional status should be optimized before surgical intervention in patients with a significant weight loss.

Positioning and placement of trocars

The patient is placed in modified “French” lithotomy position as shown in Figure 5-1 with 30-degree reverse Trendelenburg. The surgeon stands between the patient’s legs, the camera operator stands to the patient’s right, and the first assistant stands to the patient’s left. Five trocars are placed as shown in Figure 5-2. The initial port (number 1) is placed using the optical trocar in the left midclavicular line subcostally and serves as the surgeon’s operating right hand. Subsequent trocars are placed in the order numbered two through five. The basic principles of trocar position and use should be followed: the camera port (number 5) should be in the midline superior to the umbilicus. The surgeon’s left-hand working port (number 2) is placed in the right subcostal region in the midclavicular line. The retraction and assistant port (number 3) should be placed in the left midaxillary line caudad to port number 1. Trocar number 4 is used to retract the left lateral lobe of the liver and is placed in the subxiphoid region.

FIGURE 5-1 Patient positioning and operating room layout for the performance of laparoscopic esophagomyotomy.

FIGURE 5-2 Port placement for laparoscopic esophagomyotomy.

Operative technique