Relief of dysphagia associated with achalasia can be achieved though a Heller myotomy. Recently, anterior fundoplication following myotomy has received strong support and has become an integral part of our operative approach to achalasia.

We undertake laparoscopic Heller myotomy with a 5-trocar technique, with the camera place in the subxiphoid position. Such camera placement provides optimal videoscopic exposure with a 0? scope. A fan retractor through the right-sided most port provides excellent exposure to the gastroesophageal junction. The gastrohepatic omentum is opened in a stellate fashion and the right crus is freed from the esophagus and/or stomach. The dissection then involves freeing the dorsal portion of the left crus from the esophagus and stomach. The ventral portion of the esophagus is dissected from the surrounding hiatus. If a hiatal hernia is present, it is entirely reduced. Longitudinal fibers of the esophagus are divided to expose transverse muscle fibers of the esophagus. Transverse muscle fibers are divided with hook cautery, carrying the myotomy adequately cephalad and caudad to ensure division of the lower esophageal sphincter mechanism and release the obstruction at the gastroesophageal junction. Intraoperative endoscopy is undertaken to document an adequate myotomy and the absence of esophagotomy or submucosal burn.

Anterior fundoplication is constructed avoid excessive postoperative reflux. Anterior fundoplication is easily constructed and does not require complete mobilization of the fundus with division of the short gastric vessels. Finally, esophageal hiatus reconstruction is undertaken dorsal to the esophagus. The hiatus, upon reconstruction, should be snug, but not tight about the esophagus and the anterior fundoplication should reside without tension in the peritoneal cavity. The anterior fundus is then tacked to the right crus to prevent twisting of the lower esophagus or tension causing the fundoplication to become undone.

This operation provides our patients excellent palliation of achalasia, and we continue to strongly support laparoscopic Heller myotomy with anterior fundoplication for patients with troubling symptoms of achalasia.