Laparoscopic Heller’s myotomy is a specialized surgical procedure designed to treat achalasia, a rare esophageal motility disorder characterized by the inability of the lower esophageal sphincter (LES) to relax properly and impaired esophageal peristalsis. Patients with achalasia commonly experience difficulty in swallowing (dysphagia), regurgitation of undigested food, chest pain, and significant weight loss. The laparoscopic approach to Heller’s myotomy has revolutionized the treatment of achalasia, offering improved outcomes with reduced morbidity compared to traditional open surgery.

Understanding Achalasia

Achalasia occurs due to degeneration of the myenteric plexus in the esophageal wall, leading to functional obstruction at the gastroesophageal junction. This obstruction prevents the normal passage of food from the esophagus into the stomach, resulting in progressive esophageal dilation and associated symptoms. While non-surgical treatments like pneumatic dilation or pharmacologic therapy provide temporary relief, they are often insufficient for long-term management. Surgical intervention remains the gold standard, and laparoscopic Heller’s myotomy is now considered the preferred approach.

Indications for Laparoscopic Heller’s Myotomy

The procedure is indicated primarily for patients diagnosed with achalasia, especially those who have persistent symptoms despite conservative measures. Specific indications include:

Persistent dysphagia to solids and liquids

Regurgitation of undigested food

Chest pain related to esophageal spasm

Weight loss due to poor nutritional intake

Complications like esophagitis or megaesophagus

Preoperative evaluation includes a detailed clinical assessment, esophageal manometry, barium swallow studies, and endoscopy to confirm diagnosis and rule out malignancy.

Surgical Technique

Laparoscopic Heller’s myotomy is performed under general anesthesia. The procedure involves making small incisions in the abdominal wall, through which a laparoscope and specialized instruments are inserted. The esophagus and the lower esophageal sphincter are carefully exposed. The primary goal is to divide the muscles of the lower esophageal sphincter longitudinally without damaging the mucosal layer of the esophagus.

Typically, the myotomy extends approximately 6–8 cm on the esophagus and 2–3 cm onto the proximal stomach to ensure complete relaxation of the sphincter. To prevent postoperative gastroesophageal reflux—a common complication due to LES disruption—a partial fundoplication, usually a Dor or Toupet procedure, is often performed concurrently. This wrap reinforces the lower esophageal sphincter while maintaining esophageal emptying.

Advantages of Laparoscopic Approach

Laparoscopic Heller’s myotomy offers several significant advantages over traditional open surgery:

Minimally invasive: Small incisions reduce postoperative pain and scarring.

Shorter hospital stay: Most patients can be discharged within 1–3 days.

Faster recovery: Patients typically resume normal activities within 1–2 weeks.

Reduced complications: Lower rates of infection, bleeding, and respiratory complications.

Enhanced precision: The magnified laparoscopic view allows meticulous dissection, minimizing risk of mucosal injury.

Postoperative Care and Recovery

After surgery, patients are usually monitored in the hospital for 1–3 days. Initially, a liquid diet is recommended, gradually progressing to soft foods as tolerated. Pain management is achieved with minimal use of opioids, favoring non-steroidal anti-inflammatory drugs (NSAIDs). Patients are advised to eat small, frequent meals and avoid foods that could irritate the esophagus. Follow-up includes periodic assessments of swallowing function and monitoring for potential complications such as reflux, mucosal perforation, or incomplete myotomy.

Outcomes and Prognosis

Laparoscopic Heller’s myotomy has demonstrated excellent long-term outcomes, with more than 90% of patients experiencing significant relief from dysphagia and improved quality of life. Complications are relatively rare but can include mucosal perforation, gastroesophageal reflux, and, infrequently, persistent or recurrent symptoms requiring additional intervention. Regular follow-up with a gastroenterologist ensures early detection and management of any postoperative issues.

Conclusion

Laparoscopic Heller’s myotomy represents a major advancement in the surgical management of achalasia. By combining the benefits of minimally invasive surgery with precise myotomy techniques, it provides effective symptom relief, rapid recovery, and excellent long-term results. With careful patient selection, meticulous surgical technique, and appropriate postoperative care, this procedure has become the standard of care for patients suffering from achalasia, offering them renewed comfort, improved swallowing function, and enhanced quality of life.