Carl Westcott, MD. Wake Forest Medical Center , Winston-Salem, NC.

and Steve Eubanks, MD. Duke Medical Center, Durham, N.C.

Medical Illustration : Annemarie B. Johnson, CMI

Achalasia is a rare disease of esophageal motility and is the primary indication for esophageal myotomy. The application of laparoscopic technology to this procedure has decreased the wound complications and has shortened the post operative convalescence associated with the traditional open procedure.

Indications

A. Achalasia

1. History of dysphasia, vomiting of undigested food, and weight loss

2. Contrast study indicative of achalasia: "birds beak", distal stenosis and poor propagation of peristalsis.

3. Elevated lower esophageal pressures which relaxes poorly to a swallow

4. Decreased esophageal body pressures, decreased peristaltic propagation

B. Other Esophageal Dysmotility Disorders

Controversial: Diffuse esophageal spasm has been surgically treated with a complete esophageal myotomy. This procedure will require a thoracoscopic approach to achieve the recommended distance of myotomy described in the literature of open myotomies for this condition.

Contraindications

A. Inability to tolerate surgery, or general anesthesia

B. Esophageal cancer or high grade dysplasia

Preoperative preparation.

A. Same day admission/admission the night before surgery.

1. Clear liquids for 48 hours , and NPO for 8 hours preop.

2. gastric enteral feedings pre-op if malnourished or dehydrated.

B. Preoperative Medications

1. Preoperative antibiotics: 1st generation cephalosporin, one dose just prior to incision.

2. Aspiration precautions on intubation.

Accessory devices

A. Foley: if operative times or patient physiology necessitate placement

B. Pneumatic Compression Stockings

C. Video Gastroscope set up

D. Special Operative Equipment

1. Hand held laparoscopic hook cautery.

2. Suturing equipment.

3. Laparoscopic suction irrigation.

4. 30 degree angled telescope.

Room Setup

The surgeon and scrub person stand to the patient's right. The assistant and camera person are to the patent's left. A video-gastroscope with monitor are placed at the head, to the left of the anesthesia machine and anesthesiologist.

Illustrations

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Pitfalls

1. Gastroesophageal junction scarring : Establishing a defined plane between the inner circular smooth muscle of the esophagus, and the mucosa is paramount to safe completion of this procedure. Attempting this at the level of the gastroesophageal junction is often hindered by scarring at this location. Fibrosis can obliterate the usual anatomical planes. Factors influencing the amount of GE junction scarring include long standing disease, and esophageal interventions like dilation or injection of the lower esophageal sphincter. For these reasons the muscular dissection is initiated about 5 to 7 cm above the gastroesophageal junction.

 

2. Port Placement : Special circumstances exist in all cases, and judgment is invariably required for optimal port positioning. One pitfall is placing the camera too far from the xiphoid. The dissection will proceed above the diaphragm, requiring the camera to travel a greater distance in the cranial direction than is usually experienced in other abdominal endoscopic procedures.