Laparoscopic Heller Myotomy and Partial Fundoplication for Achalasia

CHAPTER 1

So this one here is the xiphoid process, umbilicus. We're gonna put the the first port. Usually, the optical port is one inch above the umbilicus or fourteen from the xiphoid process. Okay? So more or less somewhere here. Because we're gonna put the patient in reverse Trendelenburg usually the mistake is that we put the pores too low. Okay? But this one here is like this, like fourteen centimeters or a fist. Okay? You wanna have at least a fist from, like, which is ten centimeters from each port. Okay? So they're gonna put this other port, this one here at the costal margin and the costal margin. One here, which is below the left costal margin at the level midclavicular line. Okay? Then we're gonna put the liver retractor over 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, a 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 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, fifteen. And then you use the Veress needle. Yes. Now, this one here, there's a technique. It's like a scratching - scratch. So you push and you scratch. Push and you scratch. Okay. And you scratch. Okay? And so you can feel actually the - the - no, don't worry about this. And you can feel, it... Going through the fascia? Going through the fascia. Yes. Scratch. Scratch. Uh-huh. Scratch. Gas? Yeah. Should be good, right. Oh, come here. Okay. First number is 11, 9. Second one is 8 - 0.8, and 0.7. Yep. So the first one here is 0.6. It's the intra-abdominal pressure. Okay. Which is set at 14 mm. The second one is the flow. Okay. Okay? And the third one is how many liters of of CO2 are inside the belly. I see. Okay. Usually, it's between, two and three. Maybe three and a half. But, then the left one is set on fourteen. The higher you go, the higher the chance the CO2 will go into the veins and cause a pulmonary embolus. So what's the good number for intra-abdominal pressure? Fourteen. Yes. Oh, fourteen. And then the flow is 0.5 or sometimes is right now, but usually it's between 1.2 and 1.5. Okay. The rate limiting factor is this thing. Remember the law of position? Uh-huh. It's longer and short in diameter. That's it. If you give him a trocar, look how big it is. Yeah. To get the intra-abdominal pressure at target will take, you know, ten seconds with this, but it's gonna take one minute with this guy here. I see. Because the radius.

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. If not, it goes into the chest. And I try to angle upwards. Okay. More than just... Yes. The opposite. Okay. Can you switch to the thirty? Sorry. Yeah. The forty-five or thirty. Okay. Marguerite, I'm making a skin incision here. Look at that. You can see. Straight down. Yeah. What it works is your shoulder. Perfect. So you don't overshoot. Nice. Okay. Perfect. Here we go. Perfect. Let's get it connected then. Mhmm. Okay. It's tight. Perfect. Mhmm. I'll leave it there. Okay. Local to me. Sure. Can I make a stab incision there, Margarita? Accalasia. Accalasia. Okay. We gotta put the one here. Oh, I just wanna sit down. I'm gonna go with the slowly. Yep. Okay. Mhmm. Push right there. It's down here in the way. Uh-huh. It's okay. Don't worry. Push because if not, it's gonna go into the liver. It's okay. Like this, push like that. Perfect. Find the... Yes. You see? That's exactly what I want. Okay? Yeah. Okay. Okay. Right there. You see? Knife. Yeah. Can we have light 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 the hepatogastric ligament. Okay? It's very tiny and flimsy. You see if you lift it up. Yeah. Okay? You can see in transparency the first lobe of the liver or the caudate lobe, segment number one. These guys are here, these branches are branches that go from the anterior vagus nerve, which is right here to the gallbladder and the liver. You see? Okay. Right. 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's a shape of a triangle. Okay? This one here, the the esophagus is right here. You can see. Okay. Mhmm. And that's the stomach. The greater greater curvature of the stomach and the omentum, you see? The spleen is right on top. You see the spleen? Okay. That's a greater curvature of the stomach, a greater curvature, greater curvature. This one here pulsating is the right, the left and the right gastroepiploic that go all the way up to here and on top. Okay? This one here is the lesser curvature, It's 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, plaster. 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 to the right pillar of the crus, to the apex of the left pillar of the crus. Okay? One second. Yeah. Like this. Like that. Oh, okay. Okay. Pick up with the camera. Okay. Come closer here. You're not there. Okay. This one here is esophagus. This one here is the right pillar of the crus. Yeah, but... Oh, man. Hold on a sec. Can I have a RayTech? Open RayTech. Yeah. I couldn't get it tight enough. No. No. No. Just open open it up. I couldn't get it tight enough. That's the easiest part of the operation. So this one here, it's one part of the muscle. You can see the other one. Just the muscle are so close. The left and right pillar of the crus? Seams. They're so close. They may not be right. Okay? One second. Okay. Let go for a second. Uh-huh. You pull down this. Okay. Pull. Pull. Uh-huh. Go out here. The plane that we cannot see on the other one, the other side, is right here. Mhmm. So, here. Okay. Back up. Back up with the camera. Mhmm. And go on this side here. You were on the wrong plane. Okay. But it's very weird anatomy. So that's the right pillar of the crus. We are basically stripped from the peritoneal, and that the crus - the other crus is somewhere in there. Mhmm. Okay? And there we're not too much. Okay. Pick up. No. Center here. Center like this. Okay. Come closer. Pick up for a second. Pick up. Margarita, hold it. Hold it. Put it in there. Uh-huh. Grasp the other part here. Grasp it now? Down. Down. Right. Right. Right. Right there. Grasp it right there. Grasp - look. Grasp the stomach. Right here. Right here. Uh-huh. Perfect. Pull up. Perfect. Stop it like that. Lower it? Lower? Yeah. Come - come, higher. Can you put one jaw in the hole? Okay. Yeah. Let go. Open. Put one in the... Hold it. Perfect. Close. Okay. Pull down towards you. Okay. Okay, back up. Hold this guy. So, this one here is pancreas. Okay? Okay. Right here. Back up. Close over there. Closer. Here's the last. Closer. There's a last... Go. Okay. Okay. Go more. Margarita. Okay. 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 angle of His. Okay? And this one here is the - the center, center, left. Okay. No. This one here is the GE junction fat pad.

Let go. In there. That's the angle of His. From here. Okay. So this one here is the right pillar of the crus. This one here is the left pillar of the crus. The goose is in the middle right here. Okay. Yeah. That's a lot of dissection there. There's still some part that it is undissected. This part here, we have to clean it up a little bit more. That's the posterior vagus right there. Yeah. That's right. This guy there. Oh, nice. This guy. Okay? Yeah. Back up.

Controls are here. That's anterior vagus. Okay. Yes. You see the... Right on top? Yeah. This guy. Back up. So I'll go in there and here. So that's the esophagus here on top and below. It's the vagus there. See? This thing? Yeah. Okay. That's the vagus. Come closer there. Okay. So that's the plane in the posterior mediastinum. Okay. And that's a vagus. Left vagus goes anterior. Okay. Make sense? Yep. See now the esophagus is right here. Okay. It's almost freed, but it's a lot there are a lot of adhesions.

Okay. So the vagus is right here. One second. Well, look at this. This one here is the His. Okay? Okay.

So that's where the GE junction is going to be. So we had to mobilize this guy even farther down here. Yeah. 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 of the left gastric. You see? Goes from one side. Look now how big it is now. Yeah. You see? You see? Vagus is going right here on top, below. We try to clean it up as much as we can. The angle of His is right there. You see? Yeah. So we are we go back, left, left. Uh-huh. Closer. So we are one centimeter below down. Okay? Like two maybe two centimeters. Mhmm. Come closer. I'm touching the - yes, the vagus is going right here. Okay. Let's clean this up and see how big Right here. So now we're gonna go into the serosa. You do those, the longitudinal fibers, and you're gonna 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 second vessel. We cut one, two, and there's the third. So we're fine. Look at that. We are here, one inch above. Bless you. Okay? This will flip it all the way up to there. And this is all the way up to here. Okay. Oh, sorry. That's your landmark to know how... Yes. Yes. Yes. That's why I don't 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 - the angle of His is right here. So it's at least one inch. Okay? Two to three centimeters. Below. See that's a marker. Yes. I see, great. Yes. This one here is the second guy. You see? We can basically cut. You see? But this one here is the is the 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.

CHAPTER 2

Okay. You see the thing that is pushing out? Yeah. That's a... That's a submucosa. Yeah. Submucosa. Uh-huh. Okay. Let me show you this. Okay. Then you get the center. Center. Center. Okay? So that's the submucosa. Okay. So once you get in that plane... Yes. But you gotta be careful not to burn the submucosa. Okay. Our explosion. Go to the myotomy. Now you see the myotomy really nicely. See? See the circle of fibers now become oblique? Look at that. We are there. And this one here is oblique. I see. See? These link 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 the esophagus down. Theoretically, this operation could have been done from the chest by opening or just the - these small two little incisions. That's how Ellis did it. But no one has been able to replicate 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 it 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. Can you see the myotomy there? Okay. Right here? Perfect. So angle of His right here. We're 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? It curves. Oh, yeah. Okay? And it goes right there. Make sense? So it's right here. Mhmm. This one here it's all opened up. Make sense? Yeah. Right. Okay. So this one here is the portion of the mucosa. This one here is the other part of... Go right here for a second. No. You just yes. Towards me. Pull down towards you. Pull towards you. Oh, like that. Okay. That's it. I won't do - there's no other way you can go. Look at this, how big it is. Yeah. Come closer? Perfect. You see? Uh-huh. Let me see. Let me clean it up a little bit more. Apply some pressure there. So stop bleeding. Come closer. Okay. Okay. So now it's not linear anymore. Kinda. That's okay. 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 he wants to connect with the other side. You see? I see. Yeah. One side, on that side. Makes sense? Yeah. Margarita. You see? Margarita. Yeah. I'm looking. This go here. Okay. Oh, I see. Okay. Okay. Okay. Now we need the Endo Stitch. Yes. Do you like it cut to a certain length or like it whole? Seventeen - uh, fifteen centimeters. So we've completed the myotomy. And then... Now we do the Dor fundoplication. The Dor. Mhmm. There's an anterior... Yes. But you see why we do the that - well, some people do the posterior wrap to keep the edges open. Oh, I see. Okay. Because you - and then you pull it open. This one here, do we need the endoscopy to find out that we have no perforation that we cut off this 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 on like this. So is there a higher recurrence rate with the POEM? The what? With the POEM, is there a higher reference? I don't understand. With the endoscopic approach, is there a... Oh the POEM? Is there a higher recurrence of... We don't know because the studies are still too small. Can you get me closer? Stop right there. No, too close. Center here. Perfect. Because then we're gonna put a - 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 running one through the stomach, one through the crus, and one through that - through the new opening there. Endo Stitch. So through the serosa of the esophagus, right? Yes. So you start above the GE junction, then you go on the GE junction, then you go below. Yeah. Hold on a sec. Hold on a sec. Come closer. Yes. I'm trying to get this on the mucosa now. Yeah. Sorry. The... The serosa - the muscularis. Yes. So... One second. One second. One second. Come above me. Scissor? Hunter? Come closer. Okay. Hunter? Got it. Let me see how it looks. Okay. And then we're gonna fold it up like this. Oh, I see. Okay. Make sense? Yeah. Now so now you're going for the right crus? Yes. Now we're going - that's the first stitch got the fundus of the stomach, the apex of the left crura, and the left upper portion of the left edge of the myotomy. Yes. 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. Okay. This one here is gonna function like a myotomy and also is gonna function as a new valve for the - do you remember I showed you the picture? Yeah. Yeah. That's right. Okay. Okay. The ledge of - the edge of the myotomy. Yeah, show me, Margarita. Okay. These things serve to keep the myotomy open. If not, we're gonna - some people say that if you do - a Dor, eventually, the the two edges get scarred down and they approximate and the patient have recurrent dysphagia and need to have another operation. So this one here, through the myotomy and through the crus. Through the myotomy, and through the crus. Mhmm. Mhmm. Flip it over, my friend, right here. Uh-huh. It's okay. Perfect. You got it. Let go. Let go. Let go. See that there is no stitch or a cross. Okay. Can I have a stitch? We need, after this, one more. Okay.

CHAPTER 3

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