Laparoscopic Heller’s myotomy is a surgical procedure used to treat achalasia, a rare esophageal motility disorder in which the lower esophageal sphincter (LES) fails to relax properly, causing difficulty in swallowing, regurgitation, and chest pain. By cutting the tight muscle fibers of the LES, this surgery relieves obstruction and allows food to pass smoothly into the stomach. In some cases, surgeons may combine this procedure with appendectomy, the removal of the appendix, particularly when there is suspicion of appendiceal disease or as a prophylactic measure during abdominal surgery. Performing both procedures laparoscopically offers the benefits of minimally invasive surgery, including reduced pain, faster recovery, and better cosmetic outcomes.

Understanding Achalasia and Its Treatment

Achalasia is characterized by the inability of the LES to relax and abnormal or absent esophageal peristalsis. Patients commonly present with:

Progressive difficulty in swallowing both solids and liquids.

Regurgitation of undigested food.

Chest pain and heartburn-like symptoms.

Weight loss due to impaired nutrition.

Treatment options include medications, pneumatic dilatation, endoscopic interventions such as peroral endoscopic myotomy (POEM), and surgical approaches. Among them, Heller’s myotomy remains the most definitive and durable treatment, especially when combined with an anti-reflux procedure.

Why Combine with Appendectomy?

Appendectomy may be performed in combination with Heller’s myotomy for several reasons:

Prophylactic removal – Since the appendix has no critical function and can cause acute appendicitis in the future, removing it during a major abdominal procedure may prevent future complications.

Incidental pathology – If the appendix appears inflamed, enlarged, or abnormal during laparoscopic inspection, appendectomy is justified.

Convenience and efficiency – Performing both procedures in the same sitting avoids the need for a second surgery later.

Thus, combining laparoscopic Heller’s myotomy with appendectomy can be advantageous in carefully selected patients.

Surgical Technique
Preoperative Preparation

Patients undergo diagnostic studies such as esophageal manometry, barium swallow, and endoscopy to confirm achalasia.

Standard pre-anesthetic workup is done, and the patient is kept fasting for 6–8 hours before surgery.

Anesthesia and Positioning

The surgery is performed under general anesthesia with endotracheal intubation. The patient is positioned supine with legs apart (French position), allowing the surgeon to stand between them.

Port Placement

A laparoscopic setup with five small ports is commonly used. One is for the laparoscope, and the others for instruments.

Laparoscopic Heller’s Myotomy

Exposure of the esophagogastric junction – The liver is retracted, and the gastrohepatic ligament is divided to visualize the LES region.

Dissection of the esophagus – The esophagus is mobilized, and surrounding fat and tissue are carefully cleared.

Myotomy – A longitudinal incision is made through the muscular layers of the LES, extending about 6–7 cm proximally on the esophagus and 2–3 cm distally on the stomach, while preserving the mucosa.

Anti-reflux procedure – In many cases, a Dor or Toupet fundoplication (partial wrapping of the stomach around the esophagus) is performed to prevent postoperative gastroesophageal reflux.

Laparoscopic Appendectomy

Identification of the appendix – The cecum is located, and the appendix is visualized.

Mobilization – The mesoappendix containing blood vessels is dissected and sealed using clips or energy devices.

Division – The base of the appendix is ligated with endoloops or staplers, and the appendix is removed.

Specimen retrieval – The appendix is extracted through one of the small port sites.

Postoperative Care

Pain management – Minimal pain due to small incisions, managed with mild analgesics.

Diet – Clear liquids are started within 24 hours, followed by gradual progression to soft foods.

Mobilization – Early walking is encouraged to prevent clots and speed recovery.

Hospital stay – Most patients are discharged in 2–3 days.

Recovery – Full recovery typically occurs within 1–2 weeks.

Benefits of the Combined Procedure

Single anesthesia – Both conditions are addressed in one sitting, avoiding separate anesthetic exposures.

Minimal invasiveness – Laparoscopic approach ensures less pain, small scars, and faster recovery.

Future protection – Removal of the appendix eliminates the risk of appendicitis later in life.

Improved swallowing and digestion – Heller’s myotomy relieves achalasia symptoms, while appendectomy prevents potential complications.

Risks and Considerations

Like all surgical procedures, risks exist:

Mucosal perforation during myotomy.

Postoperative reflux if anti-reflux procedure is not added.

Bleeding or infection at port sites.

Adhesion formation in the abdomen.

General anesthesia risks such as respiratory or cardiac complications.

However, with experienced laparoscopic surgeons and proper patient selection, the procedure is generally safe and effective.

Conclusion

Laparoscopic Heller’s myotomy with appendectomy is a valuable combined procedure for patients suffering from achalasia who also require or may benefit from removal of the appendix. The laparoscopic approach ensures minimal trauma, faster recovery, and excellent long-term results. While Heller’s myotomy relieves the distressing symptoms of achalasia and restores normal swallowing, appendectomy provides prophylaxis against future appendiceal disease. Together, these procedures demonstrate the efficiency and versatility of modern laparoscopic surgery in addressing multiple conditions within a single operative session.