Chapter 1 of 3 · Case-Based Learning
Introduction
Introduction to Heller myotomy and case presentation
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Myotomy can be performed in a precise manner without the use of any energy source
5 millimeter trochars were used for the laparoscopic approach
An 8 centimeter silk suture is used to measure the distance from the diaphragm to the cardia
The posterior attachments of the esophagus to the hiatus are kept intact during mobilization
An arthroscopic knife is used to initiate the esophageal myotomy, then scissors deepen it
A right angle grasper spreads the muscle fibers, and once the longitudinal muscle is mobilized, traction in opposite directions achieves satisfactory separation without injury to the submucosa
The myotomy proceeds from distal to proximal, with the outer longitudinal and inner circular layers well identified
Individual circular fibers can be precisely divided by the tip of the instrument with the heel protecting the submucosa
The dissection is bloodless when performed with this technique
After reaching the proximal extent at the diaphragm, the direction of dissection is reversed to extend the myotomy onto the gastric cardia
The cardiomyotomy continues for a distance of approximately 2 centimeters
The myotomy is tested by pulling the nasogastric tube back to the hiatus and performing air insufflation
The patient had near complete resolution of symptoms postoperatively
A postoperative contrast study confirmed resolution of the esophageal obstruction
Children account for approximately 5% of all patients with achalasia
The Heller esophagocardiomyotomy is the most definitive treatment for achalasia
The four major steps of Heller myotomy are mobilization of the distal esophagus, a long esophagomyotomy carried onto the stomach as a cardiomyotomy, and an anterior fundoplication to cover the myotomy and decrease gastroesophageal reflux
The most critical part of the operation is the myotomy, where mucosal perforations can occur, typically secondary to burns from an energy source such as hook cautery