Laparoscopic Myotomy and Fundoplication for Achalasia





Surgical Anatomy





  • A comprehensive understanding of foregut anatomy and physiology is critical to undertaking surgical procedures on the esophagus for benign disease.



  • Figure 31-1 demonstrates the key anatomic structures that must be considered in the surgical treatment of achalasia.




    Figure 31-1






Preoperative Considerations





  • 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.



  • 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.



  • Oral intake is restricted to clear liquids for 2 to 3 days before surgery.



  • The patient is placed supine on the operating room table with arms abducted and a footboard in position.



  • 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.






Operative Steps



Incisions





  • The surgeon stands on the patient’s right side, the assistant on the left.



  • 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



  • A 5-mm, 30-degree laparoscope is placed through the left epigastric port.




Dissection



Mar 13, 2019 | Posted by in CARDIOLOGY | Comments Off on Laparoscopic Myotomy and Fundoplication for Achalasia
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