Laparoscopic Heller myotomy using hook electrocautery: a safe, simple, and inexpensive alternative.

BACKGROUND: Laparoscopic Heller myotomy (LHM) currently is considered the standard surgical therapy for achalasia. Historically, LHM has been associated with an intraoperative esophageal perforation rate of 5% to 10%. Recent literature has suggested that robotically assisted Heller myotomy is safer due to a reported lower incidence of intraoperative esophageal perforation than with conventional techniques. This study evaluated the results of LHM in a large series using simple hook electrocautery.

METHODS: All patients undergoing LHM with Dor fundoplication (LHMDF) for achalasia by a single surgeon (A.D.P.) from 2003 through 2006 were reviewed retrospectively at a multicenter academic institution. Demographic, perioperative, and follow-up data were collected.

RESULTS: A total of 54 patients (52% female and 48% male) underwent LHMDF for the treatment of achalasia. The average age of these patients was 50 years, although 6 patients were younger than 18 years. The average body mass index (BMI) was 26.7, although four patients had a BMI exceeding 35. The average operative time was 113 min, and the estimated blood loss was 23 ml. The average length of hospital stay was 34 h. Only one patient (1.9%) underwent conversion to an open procedure, because of inadequate exposure attributed to an enlarged liver. One intraoperative esophageal perforation (1.9%) occurred in the series, which was sutured during the original operation without sequelae. Preoperatively, Botox injection therapy was administered for 24% of the patients and endoscopic dilation for 43%. Despite evidence that preoperative Botox increases the risk of esophageal perforation, this was not demonstrated in the patient population of this study. No postoperative leaks occurred, and only 3.7% of the patients had persistent dysphagia during an average follow-up period of 5 months.

CONCLUSIONS: According to the findings, LHMDF using simple hook electrocautery is safe, inexpensive, and effective for the treatment of achalasia. The current series demonstrates that with meticulous surgical technique, intraoperative esophageal perforation is a rare event with this procedure. Hook electrocautery provides safety comparable with that of robotically assisted Heller myotomy, avoiding the added expense and operative time of a robotic system.