Five trocars are used for the operation (Fig. 10.2).

Port A is placed in the midline 14 cm below the xiphoid process and is used for insertion of a 10 mm, 30° scope. Ports B and C are placed under the right and left costal margins and should form an axis of about 100–120°. They are used for dissecting and suturing.

Port D is inserted in the right mid-clavicular line at the level of port A, and it used for the liver retractor. Port E is placed in the left mid-clavicular line, and it used for insertion of a Babcock clamp and the instrument used to take down the short gastric vessels.

After the left lateral segment of the liver is lifted and the gastroesophageal junction is exposed, the gastrohepatic ligament id divided. The dissection begins above the caudate lobe of the liver and continues proximally until the right crus is identified. The crus is then separated from the esophagus by blunt dissection and the posterior vagus nerve is identified.

The electrocautery should be used with caution next to the right pillar of the crus because the lateral spread of the current may injury the posterior vagus nerve, even without direct contact.

The peritoneum and the phrenoesophageal membrane above the esophagus are divided and the anterior vagus nerve is identified. The left pillar of the crus is separated from the esophagus. Dissection is limited to the anterior and lateral aspects of the esophagus. No posterior dissection is needed if a Dor is planned.

Grasping instruments are placed through ports B and C to expose the short gastric vessels. A bipolar instrument is inserted through port E and the vessels are transected starting at a point midway along the greater curvature of the stomach.

It is important to remove the fat pad in order to expose the gastroesophageal junction. A Babcock clamp is then inserted through port E to apply traction over the proximal stomach in order to expose the right side of the esophagus. The myotomy is then performed at the 11 o’clock position and it extends for about 6 cm on the esophagus and 2.5 cm below the gastroesophageal junction. It is helpful to mark with the electrocautery the surface of the esophagus along the line where the myotomy will be carried out. There are many instruments that can be used to perform the myotomy. We prefer an electrocautery with a 90° hook as it allows careful lifting and division of the circular fibers.

The myotomy is started about 3 cm above the gastroesophageal junction by reaching the proper submucosal plane. Subsequently it is extended proximally on the esophagus and distally onto the gastric wall (Fig. 10.3).

At the beginning of a surgeon’s experience with a laparoscopic Heller myotomy, intraoperative endoscopy is very important as it allows the visualization of the squamo-columnar junction so that the myotomy can be extended distally for about 2.5 cm from this point. However, once the surgeon has gained more experience with this procedure and has become more familiar with the anatomy, the endoscopy can be omitted.

The myotomy should not be started too close to the gastroesophageal junction because at this level the layers are not well defined, particularly if multiple dilatations or injections of Botulinum toxin have been performed. It is easier to find the proper plane at this level and then to extend the myotomy proximally and distally. If bleeding occurs from the cut muscle fibers it is important not to use the cautery but to apply gentle pressure until the bleeding stops.