Watch this detailed video on Transthoracic Heller Myotomy for Esophageal Achalasia. Learn step-by-step how this minimally invasive surgical procedure is performed to treat esophageal motility disorders, improve swallowing, and enhance patient outcomes. This educational video is ideal for medical students, surgeons, and anyone interested in advanced esophageal surgery techniques.

Surgical treatment of achalasia is still now controversial. In the last thirty years two main antithetic surgical trends developed. These differ in several technical points, particularly regarding the myotomy extends upward to the level of left inferior pulmonary vein. An adequate length of the abdominal esophagus is an important factor in maintaining gastroesophageal competence. We do not believe better functional results could be obtained by a shorter myotomy on the thoracic esophagus. On the contrary, a shorter myotomy is potentially inadequate in those intermediate motor disorders between achalasia and diffuse spasm, which are not always discriminated even by preoperative manometry. addition or not of an antireflux procedure after the myotomy.

Esophageal achalasia is a rare motility disorder characterized by the inability of the lower esophageal sphincter (LES) to relax and by the absence of normal esophageal peristalsis. Patients often present with dysphagia, regurgitation, chest pain, and weight loss. If untreated, achalasia can lead to significant nutritional deficiencies and an increased risk of esophageal dilation and megaesophagus. While pharmacological therapies and endoscopic interventions exist, surgical treatment remains the definitive solution for long-term symptom relief. Among surgical options, Heller myotomy, particularly via a transthoracic approach, has been a cornerstone procedure.

Understanding Transthoracic Heller Myotomy

Heller myotomy involves the precise cutting of the muscular layer of the lower esophagus and LES to relieve functional obstruction while preserving the mucosa. The transthoracic approach is performed through a thoracic incision, usually in the left thorax, offering direct access to the esophagus. Although minimally invasive techniques like laparoscopic or thoracoscopic myotomy are increasingly favored, the transthoracic route remains relevant in certain complex cases, such as:

• Patients with previous upper abdominal surgery

• Esophageal diverticula

• Achalasia with significant esophageal dilation or tortuosity

• Failed endoscopic interventions

Indications

Transthoracic Heller myotomy is typically indicated in patients with:

• Classic achalasia unresponsive to medical or endoscopic therapy

• Severe esophageal dilation (sigmoid-shaped esophagus)

• Prior abdominal surgery complicating the laparoscopic approach

• Need for esophageal mobilization due to anatomical considerations

Surgical Technique

Preoperative Preparation

• Complete diagnostic workup: esophageal manometry, barium swallow, and endoscopy

• Nutritional optimization if patient has significant weight loss

• General anesthesia with single-lung ventilation

Operative Steps

1. Positioning and Incision: Patient is placed in a lateral decubitus position, and a left thoracotomy or thoracoscopic ports are established.

2. Esophageal Mobilization: The distal esophagus is carefully dissected, preserving vagal nerves.

3. Myotomy: Longitudinal incision of the muscular layer of the lower esophagus and LES, typically extending 6–8 cm proximally and 2 cm onto the gastric cardia.

4. Mucosal Integrity Check: The mucosa is inspected for perforations, which, if present, are repaired immediately.

5. Optional Fundoplication: To reduce the risk of postoperative gastroesophageal reflux, a partial fundoplication may be performed.

6. Closure: Thoracic drainage is placed, and the incision is closed.

Postoperative Care

• Patients are usually monitored in a surgical ICU or high-dependency unit initially

• Early mobilization and respiratory physiotherapy are encouraged to prevent pulmonary complications

• Gradual reintroduction of oral intake, starting with liquids

• Pain management with epidural analgesia or intravenous medications

Outcomes

Transthoracic Heller myotomy has been shown to:

• Significantly improve dysphagia and regurgitation

• Achieve long-term symptom relief in most patients

• Have low rates of morbidity and mortality in experienced hands

Potential Complications include:

• Mucosal perforation

• Postoperative reflux (can be mitigated with fundoplication)

• Pneumothorax or pleural effusion

• Infection or bleeding

Advantages of the Transthoracic Approach

• Direct visualization of the esophagus in challenging anatomical situations

• Easier management of esophageal diverticula or tortuous esophagus

• Preservation of abdominal structures, particularly in patients with prior surgeries

Conclusion

Transthoracic Heller myotomy remains a safe and effective surgical option for esophageal achalasia, particularly in complex or redo cases. While laparoscopic and minimally invasive approaches are now more common, the transthoracic route offers unmatched exposure for selected patients. Multidisciplinary preoperative evaluation and meticulous surgical technique are essential to achieve optimal outcomes and minimize complications.