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Laparoscopic Myotomy

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Laparoscopic Myotomy
Technique
 
 Technical Difficulty Level =  8 - HIGH
             

 

 STEP 1: Entering the Intra-abdominal Cavity

A pneumo-peritoneum is created in the usual fashion using a Veress needle in sub-umbilical position. The first trocar is inserted [10-5mm Versaport™]  4 to 6 cm above the umbilicus.

The intra-abdominal cavity is visualized with the Telescope and intra-abdominal findings are reported [intra-abdominal pathology and inguinal hernia defects and sacs].          

A total of 5 trocars are inserted.

 STEP 2: Exposing the GE Junction

The left hepatic lobe is retracted using a ENDORETRACT II ™ retractor and the GE Junction is exposed.

 

The GE junction is meticulously dissected and preparation is made for a Toupet Fundoplication.

 STEP 3: Preparing the Fundoplication

Although the fundoplication is completed at the end of this procedure, the surgeon should takedown the short gastric vessel and mobilize the gastric fundus at this time.

A GE window is created using the MAXIRETRACT Instruments and by meticulously dissecting the medial and lateral aspect of the Gastro-esophageal junction. The GE window should be at least of 4 cm in length.

The short gastric vessels are taken down using an ULTRASHEARS INSTRUMENT or an HARMONIC SCALPEL.

 STEP 4: Performing the Myotomy - Heller Type

The lower esophagus is mobilized as proximally as possible. Six to eight centimeters should visualized above the GE Junction. Another six centimeters should be visualized on the anterior aspect of the stomach.

The vagus nerves are exposed and retracted away from the site of the myotomy.

The myotomy is started by clearing the anterior gastric wall of all fatty coverage. This is usually done with the ULTRASHEARS Instrument™ or the Harmonic Scalpel™. The myotomy is initiated immediately above the gastro-esophageal junction first using an atraumatic grasper and continuing it with the electro-cautery device (ValleyLabs™ - at low coagulating power - 20).

First, the longitudinal muscular layers are identified using an atraumatic grasper. Then, the circular layers are identified and transected using the electro-cautery. This dissection should be slow and meticulous. The circular fibers should be carefully elevated away from the esophageal mucosa, then transected, only a few at a time. The mucosa will start bulging through the myotomy site, intact. It is essential NOT to manipulate the esophageal mucosa with any instrument.

The myotomy is then extended proximally on the anterior aspect of the esophagus and distally, across the gastro-esophageal junction and on to the anterior gastric wall. The most difficult part of this dissection is at the junction of the gastro-esophageal junction and the stomach where the gastric mucosa is more adherent to the gastric muscular layers.

 STEP 5: Completing the Anti-reflux Component

The myotomy is completed by performing an antireflux procedure (low resistance) such as a Toupet fundoplication or at time a Dor anterior fundoplication. A Toupet 270 Deg. fundoplication is our favored antireflux procedure in this clinical setting.

 STEP 6: Completing the Procedure

A Blake Drain and a Nasogastric Tube should be inserted.


 

Procedural Videos
> Laparoscopic Heller Myotomy - Full

> Laparosopic Myotomy with Toupet Fundoplication


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