Chapter 78 - Esophagomyotomy

Summary

Esophagomyotomy involves splitting the muscular layers of the distal esophagus and proximal stomach while leaving the mucosa intact. Esophagomyotomy is primarily performed for esophageal diverticula and achalasia. When used to treat esophageal diverticula, the esophagomyotomy is performed in conjunction with a diverticulopexy or diverticulectomy. The most common indication for esophagomyotomy is the treatment of achalasia. This procedure is also known as the Heller myotomy, named after Ernest Heller who introduced the technique in 1913 to originally include a double cardioesophagomyotomy of the anterior and posterior esophagus. The operation was modified in 1923 by Zaaiger with the primary objective being to adequately divide the two muscle layers (longitudinal and circular) to create an anterior myotomy only.

Four approaches for esophagomyotomy have been described: transabdominal, transthoracic, minimally invasive thoracoscopic, and laparoscopic. The principle tenets of the operation are shared by all four techniques. The tenets are adequate exposure of the esophagus and gastric cardia, identification of the gastroesophageal junction by resection of epiphrenic fat pad, identification of the vagus nerves, and sufficient division of the esophageal muscle layers. Division of the muscle layers involves proximal extension onto the esophagus for 6–8 cm and distal extension onto the gastric cardia for 2–3 cm. Currently, the laparoscopic approach is favored because of technical advantages that include a shorter recovery period. The laparoscopic approach is considered the gold standard.