Laparoscopic Heller Myotomy and Anterior Partial Fundoplication

Severe symptoms and diagnosis of achalasia

There were no contraindications.

The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20-30°; a bean bag is inflated to avoid sliding of the patient; if possible an orogastric tube is placed to decompress the stomach; the surgeon stands between the patients legs, while first and second assistant stand on the right and left side respectively. A five trocar technique is used for this procedure; a first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30�° scope; a second trocar is placed in the left midclavicular line, at the same level with the first trocar, to introduce a Babcock clamp; a third trocar is placed in the right midclavicular line, at the same level of the other two trocars, and it is used for the insertion of a retractor to lift the liver; a fourth and a fifth trocar are placed under the right and left costal margins and they are used for the dissecting and suturing instruments.

1) upper endoscopy, which showed retained food in the esophagus; 2) barium swallow, which showed distal esophageal narrowing with an air-fluid level; 3) esophageal manometry, which showed type II achalasia.

We consider five steps for this operation.
1. Division of the gastro-hepatic ligament; identification of the right crus of the diaphragm and posterior vagus nerve.
2. Division of the peritoneum and phreno-esophageal membrane above the esophagus; identification of the left crus of the diaphragm and anterior vagus nerve.
3. Division of the short gastric vessels.
4. Esophageal myotomy.
5. Dor fundoplication.

The postoperative course was uneventful.

The postoperative course was uneventful.