Heller Cardiomyotomy

  • Heller myotomy is a surgical procedure in which the muscles of the cardia (lower oesophageal sphincter or LOS) are cut, allowing food and liquids to pass to the stomach.
  • It is used to treat achalasia, a disorder in which the lower oesophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.
  • Achalasia:
  • Clinical features: Patients often presents with dysphagia, chest pain, regurgitation and weight loss.
  • Investigations: Barium swallow shows a dilated esophagus with poor emptying, an air fluid level and tapering at LES giving a bird beak appearence. Esophageal manometry shows impaired LES relaxation and absent peristalsis.
  • During the procedure, the patient is put under general anaesthesia.
  • Five or six small incisions are made in the abdominal wall and laparoscopic instruments are inserted.
  1. The myotomy is a lengthwise cut along the oesophagus, starting above the LES and extending down onto the stomach a little way.
  2. The oesophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact.
  • Perforation during the myotomy.
  • A gastrografin swallow is performed after the surgery to check for leaks. 
  • If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.
  • Acid reflux 
  • Surgery is often combined with partial fundoplication to reduce the incidence of postoperative acid reflux.
  • Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink. 
  • It is considered the definitive treatment for achalasia.

Exam Question
  • Heller's operation is done for Achalasia cardia
  • Dysphagia to both solids and liquids along with episodes of intermittent chest pain & Barium swallow showing dilated lower esophagus are best treated by Heller's myotomy

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