Heller myotomy

Heller myotomy is a surgical procedure in which the muscles of the cardia (lower oesophageal sphincter or LOS) are cut, allowing food and liquids to pass to the stomach. It is used to treat achalasia, a disorder in which the lower oesophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.

It was first performed by Ernest Heller (1877 – 1964) in 1913. Then and until recently, this surgery was performed using an open procedure, either through the chest (thoracotomy) or through the abdomen (laparotomy). However, open procedures involve greater recovery times. Modern Heller myotomy is normally performed using minimally invasive laparoscopic techniques, which minimize risks and speeds recovery significantly.

During the procedure, the patient is put under general anaesthesia. Five or six small incisions are made in the abdominal wall and laparoscopic instruments are inserted. The myotomy is a lengthwise cut along the oesophagus, starting above the LES and extending down onto the stomach a little way. The oesophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact. This procedure can also be performed robotically.

There is a small risk of perforation during the myotomy. A gastrografin swallow is performed after the surgery to check for leaks. If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.

Food can easily pass downward after the myotomy has cut through the lower oesophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial fundoplication to reduce the incidence of postoperative acid reflux. In Dor or anterior fundoplication, which is the most common method, part of the stomach (the fundus) is laid over the front of the oesophagus and stitched into place so that whenever the stomach contracts, it also closes off the oesophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the oesophagus instead. Nissen or complete fundoplication (wrapping the fundus all the way around the oesophagus) is generally not considered advisable because peristalsis is absent in achalasia patients.

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Wikipedia