Achalasia is a rare but debilitating esophageal motility disorder characterized by impaired relaxation of the lower esophageal sphincter (LES) and absence of normal peristalsis in the esophageal body. This results in progressive dysphagia, regurgitation, chest pain, and weight loss. Since its first description over a century ago, the surgical approach to achalasia has evolved significantly. Today, laparoscopic Heller’s myotomy (LHM) remains the gold standard treatment for long-lasting symptom relief.

Understanding Achalasia

The condition arises from the degeneration of ganglion cells in the myenteric plexus of the esophagus. This leads to failure of LES relaxation during swallowing, causing functional obstruction. Over time, the esophagus dilates and loses motility. Diagnostic modalities include:

Barium swallow: Reveals the classic “bird’s beak” narrowing at the gastroesophageal junction.

Manometry: The gold standard, showing elevated LES pressure and absent peristalsis.

Endoscopy: Helps rule out pseudoachalasia due to malignancy.

Evolution of Surgical Treatment

In 1913, Ernest Heller described a myotomy involving both anterior and posterior esophageal walls. This was later modified to a single anterior myotomy, which remains standard today. With the advent of laparoscopy in the early 1990s, Heller’s myotomy was adapted to a minimally invasive approach, significantly improving recovery and patient satisfaction.

Principles of Laparoscopic Heller’s Myotomy

The operation involves longitudinal division of the LES muscle fibers, allowing the sphincter to relax while preserving the mucosa. The key components are:

Adequate length of myotomy – At least 6 cm on the esophagus and 2 cm onto the stomach.

Mucosal preservation – Preventing perforation of the underlying mucosa.

Antireflux procedure – Partial fundoplication (Dor or Toupet) is often added to reduce postoperative gastroesophageal reflux disease (GERD).

Operative Technique
Patient Positioning and Port Placement

The patient is placed in supine position with legs apart (French position).

A standard 5-port technique is used with a 30° laparoscope.

Exposure of the Esophagogastric Junction

The left lobe of the liver is retracted.

The gastrohepatic ligament is divided to expose the esophageal hiatus.

Mobilization of the Esophagus

The phrenoesophageal ligament is dissected.

Adequate intra-abdominal esophageal length is ensured.

Performing the Myotomy

The longitudinal and circular muscle fibers of the distal esophagus are divided sharply, exposing the underlying mucosa.

The myotomy is extended proximally (6 cm) and distally (2 cm onto the stomach).

Care is taken to avoid mucosal perforation, which occurs in 5–10% of cases but can be repaired laparoscopically if recognized intraoperatively.

Fundoplication

To prevent reflux, a partial fundoplication is added.

Dor fundoplication: Anterior 180° wrap.

Toupet fundoplication: Posterior 270° wrap.

The choice depends on surgeon preference and intraoperative findings.

Advantages of Laparoscopic Heller’s Myotomy

Minimally invasive: Smaller incisions, less pain, faster recovery.

Effective symptom relief: Over 90% of patients experience long-term improvement in dysphagia.

Low recurrence rate: Durable outcomes when the myotomy is complete.

Ability to combine with fundoplication: Reduces risk of postoperative GERD compared to myotomy alone.

Early return to diet and activities: Hospital stay is typically 1–2 days.

Complications and Challenges

While LHM is safe and effective, complications can occur:

Mucosal perforation: The most common intraoperative issue, usually managed with laparoscopic suturing.

GERD: Occurs in up to 30% of patients without fundoplication; reduced significantly when a wrap is added.

Incomplete myotomy: May lead to persistent dysphagia.

Bleeding: Rare but possible during muscle division.

Careful technique and experience are crucial for minimizing these risks.

Outcomes and Long-Term Results

Studies consistently show excellent outcomes for LHM:

Symptom relief in 90–95% of patients.

Durable improvement lasting 10–20 years in many cases.

Quality of life significantly improved compared to preoperative state.

Comparable or superior results to endoscopic interventions such as pneumatic dilatation or peroral endoscopic myotomy (POEM), though POEM is gaining popularity.

Comparison with Other Treatments

Pneumatic dilatation: Effective but carries a higher recurrence rate and risk of perforation.

POEM: A newer endoscopic alternative offering similar efficacy but with higher rates of reflux since no fundoplication is performed.

Medical therapy (calcium channel blockers, nitrates, botulinum toxin): Provides only temporary relief, reserved for non-surgical candidates.

Thus, LHM remains the gold standard for durable, safe treatment.

Conclusion

Laparoscopic Heller’s Myotomy has revolutionized the management of achalasia by providing excellent long-term relief from dysphagia with minimal morbidity. By combining precise esophageal myotomy with a protective partial fundoplication, this procedure balances effectiveness with reflux control. While newer techniques like POEM continue to expand the therapeutic arsenal, laparoscopic Heller’s myotomy remains the benchmark against which all other treatments are measured. For patients suffering from the progressive and disabling symptoms of achalasia, LHM offers a safe, reliable, and life-changing solution.