Upper GI

Heller Myotomy (Laparoscopic) with Dor Fundoplication

OPERATION: Laparoscopic Heller Myotomy and Dor Fundoplication
ANAESTHETIC: General endotracheal anaesthesia
POSITION: Supine in stirrups, legs abducted, surgeon between legs. Beanbag support. Pneumatic compression stockings. Orogastric tube inserted and removed prior to myotomy.

INDICATION:
Esophageal achalasia. Preoperative assessment: barium swallow [bird beak appearance / sigmoid oesophagus / dilated oesophagus], upper endoscopy [mechanical obstruction excluded], oesophageal manometry [absent peristalsis, incomplete LOS relaxation confirmed]. [Previous pneumatic dilatation / botulinum toxin injection — noted].

PROCEDURE:
WHO Checklist performed. Abdomen prepared and draped.

PORT PLACEMENT:
Five 10 mm ports placed. Camera port in the midline 14 cm below xiphoid. Fan liver retractor port in the right midclavicular line at the same level. Third port in the left midclavicular line for retraction. Fourth and fifth ports beneath the right and left costal margins for dissecting and suturing instruments, forming approximately 120° angles with the camera port. Pneumoperitoneum 15 mmHg.

DISSECTION:
Gastrohepatic ligament divided from the caudate lobe of the liver towards the diaphragm until the right crus was identified. Right crus separated from the right side of the oesophagus by blunt dissection. Posterior vagus nerve identified and protected — monopolar diathermy avoided in this area. Peritoneum and phrenoesophageal membrane divided above the oesophagus. Anterior vagus nerve identified and preserved attached to the oesophageal wall. Left crus separated from the oesophagus by blunt dissection. Mediastinal dissection continued anteriorly and laterally, exposing 6–7 cm of distal oesophagus. Short gastric vessels divided in their entirety to the left crus.

MYOTOMY:
Anterior fat pad removed to expose the gastro-oesophageal junction. Anterior vagus nerve preserved. Stomach retracted downward and to the left. Myotomy performed using hook diathermy in the 11 o'clock position, commencing 3 cm above the GOJ and entering the submucosal plane. Myotomy extended 6 cm proximally along the oesophagus and 2.0–2.5 cm distally onto the gastric wall — total myotomy length approximately 8–8.5 cm. Muscle edges separated to expose mucosa over 30–40% of the circumference. Mucosal integrity confirmed — no perforation. [Intraoperative endoscopy used to confirm distal extent of myotomy.]

DOR FUNDOPLICATION:
Anterior partial (Dor) fundoplication performed. Left row of sutures: three stitches incorporating the gastric fundus and left esophageal muscle wall, the uppermost incorporating the left pillar of the crus. Gastric fundus folded over the exposed mucosa. Right row of sutures: three stitches incorporating the fundus and right pillar of the crus. Two additional sutures placed between the anterior hiatal rim and the superior aspect of the fundoplication to reduce tension.

Pneumoperitoneum released. Ports removed. Skin closed with absorbable subcuticular sutures.

FINDINGS:
Achalasia confirmed intraoperatively. Myotomy performed without mucosal breach. Dor fundoplication covers exposed mucosa and protects against postoperative reflux.

EBL: Minimal. COMPLICATIONS: None.

POST-OPERATIVE INSTRUCTIONS:
Clear fluids day 1. Soft diet as tolerated. Proton pump inhibitor commenced. Postoperative pH monitoring if symptoms of reflux develop. Follow-up at 4–6 weeks.