Achalasia is a rare esophageal motility disorder characterized by the failure of the lower esophageal sphincter (LES) to relax and the absence of normal esophageal peristalsis. Patients typically present with progressive dysphagia, regurgitation, chest pain, and weight loss. The management of achalasia has evolved significantly over the past decades, with minimally invasive laparoscopic techniques now considered the gold standard due to their efficacy, safety, and reduced postoperative recovery times. Among these, Laparoscopic Heller’s Cardiomyotomy combined with Dor Fundoplication has emerged as a widely accepted surgical solution.

Indications for Surgery

Surgery is usually indicated for patients with classic achalasia who do not respond to conservative or endoscopic treatments such as pneumatic dilation or botulinum toxin injection. It is particularly beneficial in young patients or those with recurrent symptoms after endoscopic interventions. The goal is to relieve the functional obstruction at the gastroesophageal junction while minimizing postoperative gastroesophageal reflux, which is a common complication following myotomy.

Preoperative Evaluation

A thorough preoperative assessment is essential to optimize outcomes. Diagnostic evaluation typically includes esophagogastroduodenoscopy (EGD) to rule out malignancy, barium swallow study to assess esophageal morphology and motility, and high-resolution esophageal manometry to confirm the diagnosis of achalasia and evaluate LES pressures. Preoperative counseling involves discussion of the procedure, potential risks, and expected recovery, as well as dietary modifications prior to surgery.

Surgical Technique

The laparoscopic approach to cardiomyotomy offers several advantages over open surgery, including smaller incisions, reduced postoperative pain, shorter hospital stay, and quicker return to normal activities. The procedure consists of two main components: the Heller’s myotomy and the Dor fundoplication.

Patient Positioning and Port Placement: The patient is placed in a supine position with slight reverse Trendelenburg to facilitate exposure of the esophageal hiatus. Typically, four to five laparoscopic ports are inserted strategically to allow optimal visualization and instrument maneuverability.

Exposure of the Esophagus: The gastroesophageal junction and the distal esophagus are carefully mobilized. The phrenoesophageal membrane is dissected to expose the LES and the anterior surface of the esophagus while taking care to avoid injury to the vagus nerves.

Heller’s Cardiomyotomy: Using laparoscopic instruments, a longitudinal incision is made along the anterior wall of the distal esophagus and proximal stomach, extending approximately 6–8 cm on the esophagus and 2–3 cm onto the stomach. The circular muscle fibers are meticulously divided while preserving the underlying mucosa. Careful attention is given to avoid mucosal perforation, which is a potential complication.

Dor Fundoplication: After completion of the myotomy, a Dor fundoplication—an anterior 180°–200° wrap—is performed to cover the exposed mucosa and prevent postoperative gastroesophageal reflux. This involves mobilizing the anterior fundus of the stomach and securing it to the edges of the myotomy with interrupted or continuous sutures. The Dor technique is preferred in combination with myotomy because it protects the esophageal mucosa while avoiding undue tension that could compromise esophageal emptying.

Intraoperative Considerations

During surgery, careful monitoring of esophageal length and tension is critical. Intraoperative endoscopy may be used to confirm the adequacy of the myotomy and ensure mucosal integrity. Any mucosal perforation detected intraoperatively can be repaired immediately, preventing postoperative complications.

Postoperative Care

Patients typically resume oral intake gradually, starting with liquids and advancing to soft foods as tolerated. Postoperative pain is managed with multimodal analgesia. Early ambulation and respiratory exercises are encouraged to reduce the risk of postoperative complications such as pneumonia or deep vein thrombosis. Most patients experience immediate relief of dysphagia and improved quality of life.

Outcomes and Complications

Laparoscopic Heller’s myotomy with Dor fundoplication has demonstrated excellent long-term outcomes, with success rates exceeding 90% in relieving dysphagia. Complications are relatively rare but may include mucosal perforation, reflux, or, in rare cases, incomplete myotomy leading to persistent symptoms. Dor fundoplication significantly reduces the risk of postoperative reflux compared to a myotomy alone.

Advantages Over Other Approaches

Compared to open surgery, the laparoscopic approach offers smaller scars, less postoperative pain, faster recovery, and shorter hospital stay. Compared to endoscopic treatments, surgical myotomy provides durable relief of symptoms with lower recurrence rates, particularly in young patients or those with severe disease.

Conclusion

Laparoscopic cardiomyotomy combined with Dor fundoplication represents a safe, effective, and minimally invasive surgical solution for patients with achalasia. With meticulous surgical technique, careful patient selection, and appropriate postoperative care, this approach not only alleviates dysphagia but also minimizes complications such as gastroesophageal reflux, providing patients with durable symptomatic relief and improved quality of life. The evolution of laparoscopic techniques continues to refine the management of achalasia, making it a benchmark in modern gastrointestinal surgery.