I I I 1 I I I

B 5 sec

Figure 16-10 This series of drawings depicts the left thoracotomy operative approach for esophageal achalasia. A The left lung is collapsed using a single-lung ventilation technique for the right lung. The inferior pulmonary ligament is released and the esophagus dissected from its mediastinal bed. Ligation and division of the lower esophageal arteries is usually required. The dotted line in the drawing locates the point of entry into the peritoneal cavity. A true hiatal hernia is not usually present, but dissection inside the muscular edges of the hiatus exposes the phrenoesophageal membrane and a "cap" of peritoneum through which abdominal access is gained. B, The esophageal hiatus is dissected to completely free up the gastroesophageal junction. The anterior fat pad at the gastroesophageal junction is removed. These two maneuvers result in uncompromised exposure of the anatomy. C, The esophagomyotomy is begun at a convenient location on the esophageal body. The correct submucosal plane is identified by cutting the muscle between forceps that grasp and suspend the muscle. Scissors with relatively blunt tips, such as Mayo scissors, are ideal for this maneuver. The myotomy is then extended through the gastroesophageal junction/LES region and onto the stomach. This complete myotomy ensures successful reduction of the LES pressure. D, Following the myotomy, the muscular edges of the hiatus are closed. A competent but nonobstructive antireflux mechanism is established by performing a modified (i.e., four-stitch) Belsey fundo plication. The thickened muscle of achalasia provides a secure purchase for the esophageal sutures.

Figure 16-10 This series of drawings depicts the left thoracotomy operative approach for esophageal achalasia. A The left lung is collapsed using a single-lung ventilation technique for the right lung. The inferior pulmonary ligament is released and the esophagus dissected from its mediastinal bed. Ligation and division of the lower esophageal arteries is usually required. The dotted line in the drawing locates the point of entry into the peritoneal cavity. A true hiatal hernia is not usually present, but dissection inside the muscular edges of the hiatus exposes the phrenoesophageal membrane and a "cap" of peritoneum through which abdominal access is gained. B, The esophageal hiatus is dissected to completely free up the gastroesophageal junction. The anterior fat pad at the gastroesophageal junction is removed. These two maneuvers result in uncompromised exposure of the anatomy. C, The esophagomyotomy is begun at a convenient location on the esophageal body. The correct submucosal plane is identified by cutting the muscle between forceps that grasp and suspend the muscle. Scissors with relatively blunt tips, such as Mayo scissors, are ideal for this maneuver. The myotomy is then extended through the gastroesophageal junction/LES region and onto the stomach. This complete myotomy ensures successful reduction of the LES pressure. D, Following the myotomy, the muscular edges of the hiatus are closed. A competent but nonobstructive antireflux mechanism is established by performing a modified (i.e., four-stitch) Belsey fundo plication. The thickened muscle of achalasia provides a secure purchase for the esophageal sutures.

TABLE 16-4 -- Treatment of Achalasia: Esophagomyotomy and Fundoplication

Reference

Year

Improved (%)

Mortality (%)

Postoperative GERD (%)

Nelems et al.1 1

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