The gold standard for achalasia is surgical correction via laparoscopic Heller myotomy with a partial fundoplication. The goal of this technical report is to illustrate our preferred approach to patients with achalasia and to provide the reader with a detailed description of our operative technique, its rationale, and our pre and post-operative management.
Achalasia is a rare disorder of the esophagus, with an incidence of 0.5-1.2 in 100,000 cases/year, where the esophageal peristalsis is absent and the lower esophageal sphincter (LES) fails to relax, therefore causing dysphagia.1 This condition appears to be largely equally distributed among different races and gender groups. Some studies point to a bimodal age distribution, with peaks at 30 years of age and 60 years of age, while others indicated that the incidence of achalasia increases with age.
The most common presentation is dysphagia and regurgitation.2 Diagnosis is confirmed with barium esophagogram, upper endoscopy, and esophageal manometry. Manometry is the gold standard and usually shows failure of the LES to relax and complete loss of peristalsis. More refined diagnostics, such as the high resolution manometry (HRM), can identify variants and guide management based on predictable responses to medical and surgical treatments.5
Pneumatic balloon dilatation of the LES is a common approach to achalasia.6,7 However, there is a high rate of recurrence for which Heller myotomy with a partial fundoplication is a more definitive management. Newer techniques, such as the peroral endoscopic myotomy (POEM) are emerging but their performance as compared to the Heller myotomy is still to be determined.8,9
Heller myotomy (LHM) with Dor fundoplication is first line surgical treatment of achalasia. Mega-esophagus, defined as esophagus greater than 6 cm in diameter, is another esophageal pathology where studies have shown that LHM with Dor fundoplication provides excellent or good results in most of patients, even in those with a sigmoid shaped esophagus.3,1 0,11
The most common intraoperative complication of the Heller myotomy is an esophageal perforation. If the injury is recognized intraoperatively, then laparoscopic repair that includes closing the perforation with intracorporeal suturing using 4-0 absorbable sutures and a Dor fundoplication to patch the repair is sufficient. Risk factors for esophageal perforation are reoperation or previous botox injections. If an esophageal perforation is suspected immediately postoperatively, then a water-soluble contrast medium swallow is recommended and a covered stent placed with an upper endoscopy and broad antibiotic coverage is sufficient in most cases. For late presentation of esophageal perforation, an Ivor-Lewis esophagectomy is the treatment of choice as this operation will remove all the diseased distal esophagus.
Persistent or recurrent dysphagia may occur after a Heller myotomy. Persistent dysphagia may represent a technical problem with the myotomy or the fundoplication. Excessive narrowing of the esophagus can result from a short myotomy or a complete or near-complete fundoplication. Most of these cases can be corrected with pneumatic dilatation first, even though a wrong choice of fundoplication may warrant reoperation.
Recurrent dysphagia is defined as dysphagia that recurs after a period in which the patient has no symptoms. Recurrent dysphagia should raise concern for esophageal cancer, thus an upper endoscopy should be an essential part of the work up.13,14,15 If endoscopy rules out a malignancy, then one can offer the patient a pneumatic dilatation and a re-do Heller myotomy if this fails. 16,17,18 An esophagectomy is the last resort after failure of all other treatments.
- O'Neill OM, Johnston BT, Coleman HG. Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2013;19(35):5806-5812. doi:10.3748/wjg.v19.i35.5806.
- Fisichella PM, Carter SR, Robles LY. Presentation, diagnosis, and treatment of oesophageal motility disorders. Dig Liver Dis. 2012;44(1):1-7. doi:10.1016/j.dld.2011.05.003.
- Willis T. Pharmaceutice rationalis sive diatribe de medicamentorum operationibus in humano corpore. London: Hagae-Comitis; 1674.
- Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22(9):e256-e261. doi:10.1111/j.1365-2982.2010.01511.x.
- Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology. 2008;135(5):1526-1533. doi:10.1053/j.gastro.2008.07.022.
- Sweet MP, Nipomnick I, Gasper WJ, et al. The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg. 2008;12(1):159-165. doi:10.1007/s11605-007-0275-z.
- Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech. 2012;22(4):289-296. doi:10.1097/SLE.0b013e31825a2478.
- Inoue H, Minami H, Kobayashi Y, et al. Perioral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271. doi:10.1055/s-0029-1244080.
- Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc. 2012;26(11):3267-3272. doi:10.1007/s00464-012-2336-y.
- Liebermann-Meffert D, Allgöwer M, Schmid P, Blum AL. Muscular equivalent of the lower esophageal sphincter. Gastroenterology. 1979;76(1):31-38. doi:10.1016/S0016-5085(79)80124-9.
Table of Contents
- After a rapid sequence intubation, a nasogastric tube and a urinary foley catheter are placed.
- The patient is then positioned supine, propped with surgical beanbag to allow the patient to be placed in a steep reverse Trendelemburg.
- The legs are placed in the semi-lithotomy position on stirrups. The surgeon usually stands between the patient’s legs and the assistant on patient’s right side.
- Trocar Placement
- Anatomical landmarks such as the Xiphoid process and bilateral costal margins are marked prior to insufflation. A 1 cm transverse incision at the midline, two-finger breadths superior to umbilicus, is made for placement of Veress needle and abdomen insufflation.
- Once the abdomen is insufflated to a pressure of 15mmHg, the optical trocar is placed to accommodate a 10 mm 30-degree laparoscope.
- Two operating trocars (11mm each) are placed 2-3 cm below the right and left costal margins at the level of the mid-clavicular line.
- A 5 mm incision is made immediately to the left of the xiphoid process for placement of a Nathanson retractor. The retractor is positioned to expose the gastro-esophageal junction by mobilizing the hepatic left lobe laterally and superiorly.
- Another 11 mm trocar is placed at the level of the left anterior axillary line and the transverse umbilical line.
- After all ports are positioned, the patient is placed in steep reverse Trendelenburg position that allows an optimal exposure of the gastroesophageal junction by allowing all organs to fall downwards.
- Identification and Division of Gastrohepatic Ligament
- Control and Divide Accessory Left Hepatic Artery if present
- Separation of Right Crus of Diaphragm from Esophagus
- Identify Posterior Vagus Nerve
- Excision of Esophageal Fatpad
- Dissection started just proximal to first branch of left gastric artery
- Division of Peritoneum and Phreno-Esophageal Membrane
- Identify Anterior Vagus Nerve
- Dissection of Left Crus of Diaphragm to Junction with Right Crus
- Division of Short Gastric Vessels
- Mobilization of Esophagus within Mediastinum
- The gastrohepatic ligament is divided to expose the right pillar of the crus. An Allis clamp is placed at the gastro-esophageal junction to allow lateral traction and facilitate the blunt dissection of the esophagus from the right crus.
- An accessory left hepatic artery may be encountered at this point and safely transected.
- The esophageal fat pad, in the anterior abdominal esophagus, is transected to expose the angle of His, which will provide exposure needed for the cardiomyotomy.
- Cardiomyotomy consists of dividing the longitudinal and circular muscle fibers until outpouching of the submucosa is seen, with care not to perforate the submucosa. his dissection can be accomplished with the hook cautery.
- The dissection starts at the gastroesophageal junction (GEJ) where the anatomical landmarks of the longitudinal and circular muscle fibers are most consistent, and extended cranially for about 7 cm.
- Then the myotomy is extended downward 3 cm onto the stomach up to the first branch of the left gastric artery. The gastric extension of the myotomy is often the most difficult part of the operation, because it entails in dividing the clasp (or U) fibers first described by Lieberman-Maffert.10
- The anterior and posterior vagus nerves are identified and preserved throughout the dissection, frequently reassessing their course in the stomach wall.
- The cardiomyotomy is performed onto the right anterolateral aspect of the esophagus, at the 10 o’clock position, between the anterior and posterior vagal nerves.
- It is started proximal to gastroesophageal junction and extended 6 cm proximally and 2.5 - 3.0 cm distally onto gastric wall.
- Muscles edges are separated by blunt dissection to expose mucosa.
- Although a Toupet fundoplication is a good alternative, we prefer to perform a Dor fundoplication as studies have shown similar outcomes. Hence, the fundus is freed by taking down the short gastric arteries using the access from the left upper quadrant.
- Then a left row of sutures is placed that encompasses the anterior wall of the stomach and the left edge of the myotomy. The uppermost stitch includes the apex of the left pillar of the crus.
- Next, the gastric fundus is folded over the myotomy and sutured superiorly along the diaphragmatic hiatus and medially along the right edge of the myotomy with 2-0 silk interrupted sutures. This completes the 180-degree Dor fundoplication.
- Left Suture Row
- 1st suture incorporates fundus, left esophageal wall, and left crus
- Other two sutures incorporate fundus and left esophageal wall
- Fundus of Stomach folded to expose mucosa
- Right Suture Row
- Three sutures incorporate fundus and right crus
- Two more sutures incorporate fundus and esophageal hiatus
- Evaluate for Perforation of Myotomy
- Removal of Trocars
- Immediate care: before extubation, the foley and nasogastric tube are removed.
- Postoperative day 1, the patient is given a regular diet.
- Imaging of choice is a water-soluble contrast medium swallow radiography if there are concerns for esophageal perforation, otherwise, no imaging is usually needed
- Postoperative follow up is done 1 week after discharge.
- Screening: this operation does not remove the risk of esophageal squamous-cell carcinoma (SCC) or gastroesophageal reflux resulting in development of adenocarcinoma. Therefore, upper endoscopic screening every 3-4 years is usually recommended. Recurrent dysphagia merits upper endoscopy evaluation to rule out malignancy.Follow up
- Patient seen in clinic two weeks after discharge
So, this one here is the xiphoid process. Umbilicus. We're gonna put the - the first port - usually, the optical port is 1 inch above the umbilicus or 14 from the xiphoid process, okay? So more or less, somewhere here. Because we're going to put the patient in reverse Trendelenburg, usually, the mistake is that we put the ports too low. Okay, but this one here is like this - like 14 centimeters or a fist. Okay, you want to have at least a fist from like - which is 10 centimeters – from – from each port, okay? The other - gonna put this other port - this one here in the costal margin and the costal margin. One, here, which is below the left costal margin at the lateral midclavicular line, okay?
Then we're going to put the liver retractor right here. Another one – another - another trocar here, okay? Because that's the way one is supposed to work, okay? So you can have this angle between here and here to the gastroesophageal junction, okay? And then, this one here is the optic, and then we're gonna put another one, which is same line - kind of transverse umbilical line, more or less - up to here, laterally, at the junction between this line and the anterior axillary line. That's it, okay?
Now, you see that there is the incision here. We don't know if there are any adhesions below. So, the teaching is that we're gonna put the first trocar as far away from the incision, so we're gonna put it here, okay? And that's how we're gonna do it. Knife, 15. And then you use the Veress needle? Yes. Veress needle. Now, this one here - this technique is like a scratching - a scratch. So, you push, and you scratch. Push, and you scratch. And you scratch, okay? And so you can feel actually the – the – don’t worry about this - and you can feel the - go into the fascia, yes. Scratch. Scratch. That’s it.
Okay. Gas. Yeah, should be the right. So, come here. First number is 11, 9. Second one is 8, 0.8, and 0.7. Yep. So, the first one here is 0.6 - is the intrabdominal pressure, which is set at 14 millimeters. The second one is the flow, okay? And the third one is how many liters of – of CO2 are inside the belly, okay? Usually, it's between 2 and 3 - maybe 3-and-a-half - but then, the left one is set on 14. The higher you go, the higher the chances of CO2 will go into the veins and cause a pulmonary embolism.
So what's the number for intrabdominal pressure? 14. Oh, 14. Yes. And then the flow is 0.5. Sometimes, is it right now, but usually, it's between 1.2, 1.5. The rate-limiting factor is this thing. Remember, the Law of Poiseuille. It's long and short in diameter. That's it. If you give him a trocar, look how big it is. To get the intrabdominal pressure at target, we take, you know 10 seconds with this, but it's going to take 1 minute with this guy here because the - like this.
Can I take the trocar? No. I'll take the gas, thank you. No, no, hold on - yeah, put it in – put it in there. Good. Can I have the - this guy? Yes. Okay. Costal margin - I try to go below the costal margin, okay? Not to go into the chest. And I try to angle upwards. Okay, moving just - yes. Okay, can you switch to the 30? Sorry – yeah, 45 or 30. Okay, Margarita, make an incision here. Look at that. You can see - go. Straight down. Yeah. What you work is your shoulder. Perfect. So you don't overshoot. Nice. Okay, perfect. Take it out. Perfect. Let's get it connected then. Perfect. We're good there. Okay, lock on to me. Sure, can you make a stab incision there, Margarita?
Achalsia - achalsia. Okay. We're gonna put one here. Hold on just one second. I'm gonna go with a Bovie. Okay. Push right there. So I’m getting in the way. That's okay. Don't worry. Push, because if not, it's gonna go into the liver. That's okay. Like this. Push like that. Perfect. You're fine there. Yes. You see? That's exactly what I want. Okay. Yeah. Okay. Right there. You see? Nice. Can we have lights off, please? This one here is the left lobe of the liver that has been retracted laterally, okay? That is the – the lateral portion of the left lobe of the liver, okay? This one here that you see - this one here is the lateral portion of the left lobe of the liver. That's the left lobe of the liver, and this one here is the falciform ligament. You see? Yes. Perfect. Okay. This one here is a ligament that goes from the liver, okay, to the stomach. So it's called a hepatogastric ligament, okay? It's very tiny and flimsy. You see, if you lift it up – okay? You can see in transparency the first lobe of the liver - of the caudate lobe - segment number one.
These guys, here, these branches are branches that go from the anterior vagus nerves, which is right here, to the gallbladder in the liver. You see? Right. Okay, we can cut them. There is no problem in doing this, okay? This one here is a small phrenic vein, okay? This one here is the triangular ligament. See? It has the shape of a triangle, okay? This one here, the esophagus, is right here. You can see, okay? And that's the stomach.
The greater – greater curvature of the stomach - and omentum, you see? The spleen is right on top. You see the spleen? Okay. That's the greater curvature of the stomach - greater curvature, greater curvature. This one here pulsating is the right - the left and the right gastroepiploic. They go all the way up to here and on top.
Okay. This one here is the lesser curvature - is right there. Perfect. Then you go to the pylorus - to the antrum here, first, and then the pylorus you can't really see because it's somewhere over there plus there, okay? That's it. Perfect. So, we're gonna grasp the anterior wall of the stomach right below the GE junction, and you tent it up, okay?
So, the operation you start by taking down the hepatogastric ligament. This one here becomes the phrenoesophageal membrane. And we're gonna go from the apex of the left pillar of the crus - apex of the right pillar of the crus to the apex of the left pillar of the crus, okay? Hold on a second. Like this. Okay. Okay. Back up with the camera. Okay. Come closer here. Right there. Okay. This one here is esophagus. This one here is the right pillar of the crus. Yeah, but... Come in closer. Can I have a Ray-Tec? Open Ray-Tec. Yeah, I couldn't get it tight enough - no, no, no, just open. Open it up. That’s the easiest part of the operation. So this one here is one part of the muscle. Can’t see the other one. Just the muscles are so close. The left and right pillar of the crus – seems - they are so close. I may not be right, okay? Hold on a second.
So, okay. Let go for a second. You pull down this, okay? Pull. Pull. Go up here. The plane that we cannot see on the other one - the other side - is right here. So, here, okay. Back up. Back up with the camera. Go on this side here. You were on the wrong plane. Come closer here. Okay, but that’s very weird anatomy. So that's the right pillar of the crus, and we are basically stripped from the peritoneal. And then crus - the other crus - is somewhere in there. Okay. And I will not put too much.
Okay, back up - no, center here. Center like this. Okay. Come closer. Back up for a second. Back up. Let go. Keep going. Margarita, hold it. Hold it. Put it in there. Grasper. The other part here. Grasper - no. Gra – down - down. Right, right, right! Right there. Grasper, right there. Gra - grasp the stomach. Right here, right here. Perfect. Pull up. Perfect. Stop like that. Pull - lower it. Lower. Yeah, come clo - come higher. Now, can you put one - Joe - in the hole? Okay. Yeah, let go. Open. Put one in the - hold this. Perfect. Close. Okay. Pull down towards you. Okay. Okay, back up. Hold this guy. So, this one here is pancreas. Okay. Okay, right here. Okay, closer there. Come closer. There's the last. Then come closer there. Come closer. There's a last… Back up for a second. Let go. Okay. Okay, go more, Margarita.
So, now - now, what we did is this. Just liberated - freed the entire - so it goes on the other side, okay? So, there is still some part missing there. This one here - you can see that's the angle of His, okay? And this one here is the - center – center - left. Okay. No, this one here is the GE junction of fat pad. Let go, right there. That's the angle of His. Come here. Okay. So, this one here is the right pillar of the crus. This one here is the left pillar of the crus. The crus is in the middle, right here. Okay.
That's a lot of resection there. There's still some part that is unresected. This part here we have to clean it up a little bit more. That's the posterior vagus, right there. This guy there. This guy, okay? Back up. Come closer, here. That's the anterior vagus. Alright, perfect. Okay. Yes. You see the – right in front? Yeah. This guy. Right there. Yeah, I see it. Back up. So, I’ll go in right there, right here. Oh, that's esophagus here on top and below. That's the vagus there. See? This thing? Okay, that's the vagus. Come closer there. Okay, so that's the plane in the posterior mediastinum. Okay, and that's the vagus. Left vagus goes anterior. Makes sense? See now, the esophagus is right here. Okay, it's almost freed, but it's a lot – there are a lot Sew additions.
So the vagus is right here. One second. Well, look at this. This one here is the His, Okay? So, that's where the GE Junction is going to be. So, we have to mobilize this guy even further down here. So, the vagus is right there. You can see the GE junction that goes right here. See? Right here and right there.
You see this one here is the first gastric artery - the first branch of the left gastric. You see? Goes from one side. Look now how big it is now. You see? You see? Vagus is going right here and top below. We tried to clean up as much as we can. Angle of His is right there. You see? So, we are - back. Left. Left. Closer. So, we are 1 centimeter below down, okay? Like 2 - maybe 2 centimeters. Come closer. I’m touching the - yes, the vagus is going right here. Let's clean this up and see how big - right here. So now, we're going to go into the serosa. And you will expose the longitudinal fibers, and you're going to go into - transect those a little bit. Yes. Okay. Come closer. It's okay. Small little vessel. It’ll be fine. So let's go below. See there's the - the second vessel. We got one, two, and that's the third. So we are fine. Look at that. We are - here, one – one inch above the - bless you. Okay. This - we flip it all the way up to there. It's all the way up to there. Okay. Oh, sorry.
So that’s your landmark. You know how high up you got to go. Kinda - yes. Yes. Yes, that's why I'll use endoscopy. You see? So... You can see clearly this one here is the first or the second. I think the first was here. Right there. Okay? And the second - or maybe this one here is just the first. Just the first branch. Okay, which is - angle of His is right here. So, it's at least 1 inch, okay? 2 to 3 centimeters. See that's the marker. Yes. I see. So when you have a hiatal hernia though, then that makes it more difficult, right? Hold this. Hold it. So and this is the spur? Yes. This one here is the second guy. You see? And we can basically cut. You see? This one here is the – is esophagus. See? From here to here. Okay. See? That's the second branch. Okay. Look how big it is now - from here to there. Okay, now let's clean it up.
So where do we start the myotomy? Always on top. Okay. Okay, come closer. Okay, come closer. You see that thing that is pushing out? Yeah, that’s the - that's the submucosa. Okay, let me show you this. Margarita, you get the center – center - center. Okay. So, that's the submucosa. So, once you get in that plane, then you can - yes, but you got to be careful not to burn the submucosa. Okay, our exposure. Go to the myotomy. Now you see the myotomy really nicely. See? See the circular fibers now become oblique? Look at that. We are there, and this one here is oblique. See? These linked fibers? Which is okay. We are very far away from the submucosa, so...
So let me stop for a second. So we are pulling the sta - the esophagus down. Theoretically, this operation could be done from the chest by opening just the – the - these small, two little incisions. That's how Ellis did it, and no one has been able to replicate the - the – this – the paper of Ellis. Only him, okay? So what people do is say, "Okay, let's go from the belly," but we'll do it in - we'll do from the belly, but we'll – we’ll go down in the - in the GE junction and in the stomach. Okay.
Okay, let's go in. Okay, see the myotomy there? Okay. Right here. Set for it. Oh, perfect. So, angle of His right here - over here - and we are - look how far down we are. Okay. So look at this. The GE junction is here. You see? It's right there. See that it curves? Curves. Okay, and it goes right there. Makes sense? So it's right here. This one here - it's all opened up. Makes sense? Yeah, yeah. Okay. So this one here is a portion of the mucosa. This one here is the other part. Over here for a second. You see? That's submucosa. That's… No. You just - yes, towards me. Pull down towards you. Pull towards you. Yeah. Okay, that's it. I won't do – there’s no other way you can go. Look at this - how big it is. Come closer. Perfect. You see? Let me see. Let me clean it up a little bit more.
Apply some pressure there. It’s almost stopped bleeding. Come closer. Okay. Okay, so now it's not bleeding anymore. Kind of. That's okay, but that's humongous. See the GE junction? Hold on a second - back up - back up - back up. See the GE junction there. Right here. See, because it wants to - connect with the other side. You see? I see, yeah. Other side - on that side. Makes sense? Yeah. Margarita, you see? Margarita? Yeah. This goes here. Okay.
Okay, now we need the Endo Stitch. Yes. Now you cut to a certain length or like the whole? 17 - 15 centimeters. So, we've completed the – the myotomy. Now we do the Dor fundoplication. Yes. But you see why we do – why – well, some people do the posterior route to keep the edges open now. Oh, I see. Okay. Because you pull it front, and then you pull it open. This one here - do we need endoscopy to find out that we have no perforation and that we can off this pa - did we cut all the – the – there is no perforation. We don't need endoscopy. Did we cut all the circular fibers? You saw that. There is no circular fibers. Right. Are we below the GE junction? Yes - because we saw it, and we saw the markers. So there is no need for the endoscopy. That's the reason why I don't use it. Perfect. Just leave it there. Just leave it like this. Hold – hold it like this.
So is there a higher recurrence rate of the POEM? Wait, what? The POEM - is there a higher recurrence? I don't understand. With the endoscopic approach? Is there a – oh, the POEM - higher recurrence? We don't know because the studies are still too small.
Can - can you come closer? Stop, like that. No, too close. Center here. Perfect. Because there we're gonna put the - see that? This one here - the short gastrics. Okay. Okay, so we're gonna put one here and here – one into the crura - and then one, two, and three to keep this open, okay? Oh, I see. Okay? So you're putting one through the sternum, one through the - yeah, Endo Stitch - through the mid-opening - so through the serosa of the esophagus, right? Yes. So you start above the GE junction, then you go on the GE junction, and then you go below? Like three stitches? Yeah, hold on a second. Hold on a second. Come closer. Yes, I'm trying to get this - the mucosa out. No, sorry the - the muscularis? Yes. So you're stepping - hold on. One second. One second. Come - come above me. Scissor. Hunter. Come closer. Okay, Hunter. Got it? Let me see how it looks.
Okay. Then we're going to fold it up like this, okay? Makes sense? Now so - now you're going for the right crus? Yes. Now we're going - no - that's - the first stitch goes the fundus of the stomach, the apex of the left crura, and the left upper portion of the left edge of the myotomy, okay? Now, we're gonna do the same thing here and here. So, there are three - there are two rows of sutures. The first row is the left one. The first one gets the fundus of the stomach, the apex of the crus, and the myotomy. The second and the third get the - the stomach and the myotomy - the stomach and the myotomy. Then we'll fold it over, and the edge of the - this guy here, the short gastrics, will get the myotomy only. If you put myotomy, myotomy, myotomy, eventually the first stitch, we can put the first one, you see? But if we - if we put the stitches around here, you will tent up the - this one here - too much. See? Too much. And now you see, the patient can't swallow. Makes sense? Because this one here is too tight. Okay, but if you put it here, it's gonna be fine. This one here is going to function like a myotomy, and also, it's gonna function as a new valve for the-do you remember I showed the picture? Yeah.
Okay. Alright. Okay, the ledge – the edge of the myotomy, you got to show me, Margarita. Okay. These things serve to keep the myotomy open. If not we're gonna - some people say that if you don't my – a – a Dor, eventually, the - the two edges get scarred down in the approximate, and the patient has recurrent dysphagia and needs to have another operation. So this one here - through the myotomy and through the crus. Through the myotomy and through the crus. Flip it over. My friend, right here. It's okay. Perfect, you got it. Let go. You let go. Let go. See that there is no stitch or a cross. Okay, can I have a stitch? We need a after this, one more.