Heller Myotomy via Open Approach
An upper midline or left paramedian incision is made. A general exploration of the abdomen is undertaken, with particular attention paid to the duodenal wall for evidence of scarring or deformity. The left hemiliver is then mobilized by dividing the triangular ligament to expose the lower esophagus. Small bands between the stomach and spleen are also divided to avoid tearing of the splenic capsule. The xiphoid may have to be excised to afford adequate exposure.
The peritoneum over the esophagus is divided, and the stomach is retracted downward. The gastrohepatic ligament is clamped and divided to allow anterior mobilization of the esophagogastric junction (EGJ). The phrenoesophageal ligaments are divided, and the esophageal fat pad is excised. The surgeon's finger is then passed around the esophagus to finalize mobilization of the esophagus and to delineate the constricted portion.
All tissue is cleared from the anterior surface of the esophagus with right-angle clamps, and any blood vessels are divided. The nasogastric tube should be aspirated during this portion of the procedure.
The myotomy is made by dividing all of the circular and longitudinal (collar-sling) muscular fibers above the area of constriction. The incision is extended 4-6 cm on the esophagus and 1.5-3 cm onto the gastric cardia to reduce outflow resistance. The muscularis should be "undermined" to allow wide separation of esophageal muscles, but care must be taken to avoid making an incision entirely through mucosa.
Intraoperative esophagoscopy is widely used for determining the length and depth or adequacy of the myotomy. Intraoperative manometry and use of the Foley catheter (to make the myotomy incision over the balloon and to distend the constricted segment) have been described but are infrequently used in clinical settings. [19]
A search for inadvertent enterotomies through mucosa is conducted, and any such injuries found are repaired with silk. At this point, pyloroplasty or posterior gastroenterostomy is performed if vagotomy was done. Some prefer to do pyloroplasty on all patients. The Foley catheter can be maintained to act as a temporary gastrostomy, after the tube is secured and the stomach anchored to the abdominal wall. Fascia and skin closure is then completed. (See the image below.)
Reoperation for failed myotomy
A failed myotomy, defined as a high lower esophageal sphincter (LES) pressure with persistent symptoms, may be best treated by attempting pneumatic dilation. However, reoperation is required after 2.9% of open Heller myotomies. [21] According to a study of the literature by Gouda et al, the reasons for reoperation were incomplete myotomy (51.8%), onset of reflux (34%), megaesophagus (16.2%), and esophageal carcinoma (2.03%). [22]
Reoperative myotomy is a reasonable option for patients with symptoms of dysphagia, an elevated LES pressure by manometry, and reasonably well-preserved esophageal motility. Reoperation can be attempted laparoscopically, [23] depending on the presence and extent of adhesions. Entering the field through the thorax may provide cleaner dissection.
Reasons cited for failure of a myotomy include an incision that is not long or deep enough and the presence of gastroesophageal reflux (GER) and its complications (stricture). Treatment of inadequate myotomy consists of performing a second myotomy, with a subsequent nonobstructive antireflux repair.
Treatment of strictures may include esophagogastrostomy, esophagogastrectomy, cardioplasty, jejunal or colonic interposition, or subtotal gastrectomy. Esophagogastrectomy is also sometimes offered to patients with persistent dysphagia and significant esophageal dilatation.
Postoperative Care
The patient is maintained on NPO (nil per os) status for 24-72 hours and receives intravenous fluids and parenteral analgesics. A diatrizoate meglumine–diatrizoate sodium swallow is performed to confirm that there is no extravasation of contrast, and a barium swallow is performed to detect obstruction. If test results are negative, clear liquids are started, and the patient's diet is advanced as tolerated. At discharge, oral analgesics and a stool softener are prescribed.
Complications
The most significant early complication of open Heller myotomy is mucosal perforation, which should be identified and repaired intraoperatively. Late complications include gastroesophageal reflux disease (GERD) and dysphagia. Reflux is common (12%), [1] especially when no concomitant fundoplication is performed. Peptic strictures, Barrett esophagus, and persistent dysphagia are also possible complications after Heller myotomy.
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Nonrelaxing lower esophageal sphincter.
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Heller myotomy for achalasia.
