Laparoscopic Heller's Myotomy
- three 5mm, two 12mm disposable trocars
- 30 degree endoscope
- Three 5mm fenestrated Johan grasping forceps
- 5mm Harmonic scalpel
- Nathansen retractor
- Two 5mm needle holders
- 5mm harmonic scalpel
- 5mm suction
Position the patient supine with 30% reverse Trendelenburg. Either stand between the patients legs or on the patients left. The monitor is placed on the patients right hand side.
Place the 12mm port in the midline, mid way between the xiphisternum and umbilicus. Place 5mm left and right operating ports 5-6cm lateral to the 12mm port. Introduce the Nathansen liver retractor through a 5mm stab incision below the xiphisternum and elevate the left lobe of the liver.
The first step is to define the hiatus, distal oesophagus. This is done by retracting the stomach towards the left lower quadrant. Take care not to grasp the stomach too vigerously as gastric perforations do occur! This maneuvre places the phreno-oesophageal membrane on traction.
Begin the dissection by incising the portion of the gastrohepatic (lesser) omentum by above the hepatic branch of the anterior vagus and so identify the caudate lobe of the liver and the right crus of the diaphragm. Avoid/preserve the left hepatic artery (present in 1/4 patients). Free the right crus from bottom to top and from anterior to posterior retracting the stomach to the patients left. The medial portion of the right crus leads into the mediastinum and is entered by blunt dissection (see below).
Expose the oesophagus anteriorly followed by the left crus whilst pulling the stomach to the right hand side. Lift the oesophagus and dissect the inferior part of the left crus. Meticulous haemostasis is critical. Irrigation should be kept to a minimum. Finally move to the anterior crural confluence sweeping the oesophagus downward and to the right. Divide the anterior crural tissue and identify the left crus laterally.
Dissect the left crus as completely as possible along with the attachments of the fundus to the left diaphragm ans so create a retro-oesophageal window. The dissection of the hiatus is now complete. Whilst our preference is to use the harmonic scalpel it is not essential.
Circumfrential dissection continues inside the mediastinum using blunt dissection. Leave the vagi in contact with the oesophagus. Mobilize about 10cm of oesophagus. Remember that there is a tendency to dissect towards the left pleura - don't! If you havent done so already, free the fundus from its diaphragmatic attachments and divide the gastrophrenic ligament. If the fundus can not be mobilized, divide the short gastric vessels as necessary with the harmonic scalpel. Ensure that the fundus is sufficiently mobile to be brought through the retro-oesophageal window using a fenestrated forceps.
After completing the posterior dissection pass a grasper via the left hand port behind the oesophagus and over the left crus. Pass a soft tape around the oesophagus and use this as a retractor.
Incise the anterior epiphrenic fat pad to allow the myotomy to extend into the stomach. Start the myotomy with scissors just above the junction on the anterior surface of the oesophagus. Seperate the longitudinal fibres bluntly to allow the closed scissors to be gently placed below the circular muscle. Open the scissors, rotate through 90 degrees and cut the muscle. Use a monopolar hook to divide the elevated circular muscle. Extend proximaly for 6cm, passing under the anterior vagus nerve.
Carry the myotomy distally into the stomach for 2cm. This latter manoeuvre is a little more difficult as the muscularis is thinner and more firmly attached to the mucosa. DO NOT DIATHERMY ANY MUCOSAL BLEEDING - it stops!
Pull back the oro-gastric tube and inject dilute methylene blue *1 ampule in 250mls saline) and look for any mucosal perforation. Close any perforation with 4-0 vicryl and repeat.
Finally compele the antireflux procedure. Us an anterior Dor fundoplication for the most dilated oesophagus as aposterior wrap tends to cause a degree of obstruction. If the hiatus is patulous, close it loosly with one or two sutures. Start just above the aortic decussation. Intracorporal knotting is fast.
Grasp the fundal wrap (mid portion posteriorly) and pass it left to right through the retro-oesophageal window with a upward clockwise twisting movement. Manipulate both the posterior and anterior fundic lips to allow the fundus to envelope the oesophagus without twisting.
Both valves of the wrapped fundus are then sutured to the cut edge of the oesopageal muscularis, avoiding the anterior vagus with four non absorbable multifilament sutures.
When an anterior fundoplication is performed, role the fundus over the exposed mucosa and place 2-3 interrupted sutures between it and the cut edge of the muscularis to the left of the oesophagus and 3 between it and the anterior crural arch ending with 3 sutures to the cut muscularis on the right.
Allow a soft diet the following morning. If there was a perforation check with a gastrograffin swallow. NB Unrecognised perforation of the oesophagus or stomach are the most serious of complications; recognition and repair is the key.
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