Step 1
Surgical Anatomy
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A comprehensive understanding of foregut anatomy and physiology is critical to undertaking surgical procedures on the esophagus for benign disease.
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Figure 31-1 demonstrates the key anatomic structures that must be considered in the surgical treatment of achalasia.
Figure 31-1
Step 2
Preoperative Considerations
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Achalasia is a motility disorder of the esophagus caused by destruction of ganglion cells in Auerbach myenteric plexus, leading to impaired relaxation of the lower esophageal sphincter (LES). Esophageal body aperistalsis is believed to be a secondary event. Progressive dysphagia to both solids and liquids is the symptomatic hallmark of achalasia.
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The barium esophagogram typically demonstrates loss of peristalsis in the smooth muscle of the distal two thirds of the esophagus as well as the classic “bird’s beak” tapering at the LES. Upper endoscopy helps eliminate a pseudoachalasia diagnosis if no tumor is identified. Esophageal manometry establishes the diagnosis by showing failure of LES relaxation and esophageal body aperistalsis.
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Oral intake is restricted to clear liquids for 2 to 3 days before surgery.
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The patient is placed supine on the operating room table with arms abducted and a footboard in position.
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After general anesthetic induction with a single-lumen endotracheal tube, flexible esophagoscopy is performed to assess the adequacy of foregut preparation. If this assessment is inadequate, the surgeon may elect to reschedule the procedure. The endoscope may be left in the stomach during the myotomy and fundoplication.
Step 3
Operative Steps
1
Incisions
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The surgeon stands on the patient’s right side, the assistant on the left.
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Five abdominal ports are placed on the anterior abdominal wall, similar to our approach for a laparoscopic Nissen fundoplication: one cut-down 10-mm port in the right epigastrium and four 5-mm ports in the bilateral subcostal, left epigastric, and right flank locations ( Fig. 31-2 ).
Figure 31-2
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A 5-mm, 30-degree laparoscope is placed through the left epigastric port.
2
Dissection
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The left lobe of the liver is lifted upward with a Diamond-Flex retractor, which is secured with a self-retaining system placed on the left side of the table. With the patient in maximal reverse Trendelenburg position, the dissection begins by dividing the gastrohepatic ligament and exposing the diaphragmatic crura bilaterally. The hiatus is circumferentially dissected, and a window is created behind the posterior vagus for subsequent passage of the fundus. The short gastric vessels are ligated using the ultrasonic shears in preparation for the partial fundoplication after the myotomy is completed.
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The anterior gastroesophageal junction (GEJ) fat pad is elevated working from left to right and from distal to proximal with preservation of the anterior vagus nerve.
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The GEJ is identified by the transition from longitudinal esophageal muscle to gastric serosa.
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The right and left crural pillars are reapproximated posteriorly using interrupted 0 nonabsorbable suture.
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Dilute epinephrine (1:20,000) may be injected in the submuscular plane above the GEJ using a straight cholangiogram needle ( Fig. 31-3A ). The esophagomyotomy is initiated using the ultrasonic shears (see Fig. 31-3B ) or laparoscopic scissors and carried out as far proximally on the anterior esophagus as can be visualized (typically 6 to 8 cm above the GEJ). Endoscopic peanuts facilitate completing a 180-degree anterior myotomy (see Fig. 31-3C ). The myotomy is extended 2 to 4 cm onto the gastric cardia ( Fig. 31-4 ).
