From the Guidelines
Heller myotomy with fundoplication is a surgical procedure for treating achalasia, involving a longitudinal incision through the muscle layers of the lower esophageal sphincter, followed by a partial fundoplication to prevent postoperative gastroesophageal reflux. The procedure begins with accessing the esophagus, either through laparoscopic or open approach, with the laparoscopic method being preferred due to less postoperative pain and faster recovery, as supported by recent guidelines 1. The Heller myotomy portion involves making a longitudinal incision through the muscle layers of the lower esophageal sphincter and extending it 6-8 cm proximally on the esophagus and 2-3 cm onto the stomach. Care is taken to preserve the mucosa while completely dividing the circular muscle fibers.
Following the myotomy, a partial fundoplication is performed to prevent postoperative gastroesophageal reflux. The most common type is the Dor (anterior) fundoplication, where the anterior fundus of the stomach is wrapped around the front of the esophagus and sutured in place. Alternatively, a Toupet (posterior) fundoplication may be performed, wrapping the fundus around the posterior aspect of the esophagus. The choice between total or partial fundoplication should be left to the preferences and expertise of surgeons, as stated in the international network on oesophageal atresia (inoea) consensus guidelines 1.
Key steps of the procedure include:
- Accessing the esophagus through a laparoscopic or open approach
- Performing a longitudinal incision through the muscle layers of the lower esophageal sphincter
- Extending the incision 6-8 cm proximally on the esophagus and 2-3 cm onto the stomach
- Preserving the mucosa while completely dividing the circular muscle fibers
- Performing a partial fundoplication to prevent postoperative gastroesophageal reflux. Postoperatively, patients typically start with clear liquids and advance to a soft diet over several days, with most patients experiencing immediate relief of dysphagia, though some may require additional interventions if symptoms persist or recur, as discussed in the context of achalasia treatment 1.
From the Research
Steps of Heller Myotomy and Fundoplication
The steps of Heller myotomy and fundoplication are described in several studies, including 2 which outlines a 5-step process for performing a laparoscopic Heller myotomy and a Dor fundoplication.
- The surgical approach is favored in many centers as it is very effective in relieving symptoms, while avoiding pathologic gastroesophageal reflux in most patients.
- Laparoscopic Heller myotomy with or without partial fundoplication is a matter of debate, as discussed in 3.
- The choice of fundoplication, such as Dor or Toupet, is also an important consideration, as noted in 4.
Types of Fundoplication
Different types of fundoplication can be used in conjunction with Heller myotomy, including:
- Dor fundoplication, which is described in 2 and 4
- Toupet fundoplication, which is discussed in 4 and found to be preferred over Dor fundoplication in some cases
- Anterior partial fundoplication, which is mentioned in 3 and 5
Surgical Approach
The surgical approach for Heller myotomy and fundoplication can vary, including: