Laparoscopic Esophagomyotomy
Laparoscopic esophagomyotomy uses the magnification and precise dissection of minimally invasive surgery to divide the hypertrophied distal esophagus associated with esophageal achalasia. This operation has largely supplanted the older transthoracic Heller myotomy, which required a left thoracotomy. References at the end of this chapter give details of the transthoracic myotomy (now generally performed thoracoscopically), which is still useful when a long-segment myotomy must be performed. Because achalasia is generally limited to the distal esophagus, the exposure attained at laparoscopy is usually ample.
Addition of a partial fundoplication is optional. The technique described here brings the fundus of the stomach anteriorly, where it may serve as a buttress for the myotomy. It is particularly useful if inadvertent entry into the esophagus has been made and repaired.
Steps in Procedure
Obtain laparoscopic access—five ports are generally used
Retract liver up toward diaphragm
Excise esophageal fat pad and clean peritoneum from anterior surface of esophagus
Begin myotomy at convenient place in thickened distal esophagus
Extend distally 1.5 to 2 cm on stomach, proximally to thin muscle of esophagua
Confirm adequacy of myotomy by passing esophagogastroduodenoscope
Consider adding partial fundoplication—Dor or Toupet
Dor—roll stomach up over myotomy and suture to edges
Toupet—Mobilize Posterior to Esophagus and Bring Fundus Behind
Suture stomach to edges of myotomy
List of Structures
Diaphragm
Crura, right and left
Esophageal hiatus
Median arcuate ligament
Esophagus
Stomach
Belsey’s Fat Pad
Artery of Belsey
Phrenoesophageal ligament
Liver
Segment I—caudate lobe
Left lobe
Segments II and III
Coronary ligaments
Left triangular ligament
Ligamentum Teres Hepatis
Falciform ligament
Subphrenic space
Greater omentum
Lesser omentum
Colon
Pericardium
Phrenic nerves
Inferior phrenic artery and vein
Left gastric artery
Left and right vagus nerve
Hallmark Anatomic Complications
Injury to esophagus
Injury to vagus nerves
Injury to stomach
Exposure of Distal Esophagus and Proximal Stomach (Fig. 48.1)
Technical Points
Set up the room as described for laparoscopic fundoplication (see Chapter 47). The trocar sites and initial exposure are identical. Confine dissection of the esophageal hiatus to the anterior and lateral aspects of the esophagus; unless a partial fundoplication is planned, it is not necessary to dissect behind the esophagus (Fig. 48.1A, B). Visually confirm the thickened, narrowed segment of esophagus and mobilize the esophagus into the abdomen until dilated proximal esophagus is seen.
Excise Belsey’s fat pad with electrocautery or ultrasonic shears (Fig. 48.1C, D). This allows unimpeded access to the gastroesophageal junction.
Anatomic Points
This dissection is confined to the anterior and lateral esophagus, in contrast to laparoscopic Nissen fundoplication, in which a more extensive dissection includes creation of a window behind the esophagus. As for Nissen fundoplication, dissection proceeds by outlining the crura of the diaphragm. These crura combine to form a muscular tunnel 2- to 3-cm long through which the esophagus and vagus nerves pass into the abdomen. There is considerable variability in the manner in which the fibrous and muscular parts of the esophageal hiatus form a sling around the esophagus; in actuality, dissection of the anterior and lateral parts of the hiatus rarely is affected by these variants. The median arcuate ligament crosses over the aorta just cephalad to the origin of the celiac axis and is not generally seen.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
