Heller Myotomy
What the Examiner Expects
A longitudinal myotomy of the lower esophageal sphincter performed laparoscopically for achalasia. The examiner expects you to confirm the diagnosis with high-resolution manometry (showing aperistalsis and incomplete LES relaxation), describe the barium swallow finding (bird's beak), and differentiate achalasia subtypes. The myotomy must extend at least 6 cm proximally on the esophagus and 2–3 cm distally onto the gastric cardia. A partial fundoplication (Dor 180° anterior is most common) must be added to prevent postop reflux. You should know that peroral endoscopic myotomy (POEM) is an alternative, but does not include an anti-reflux procedure.
Key Examiner Focus Points
- Indication: achalasia confirmed by manometry (aperistalsis + failed LES relaxation)
- Myotomy extends 6 cm on esophagus and 2–3 cm onto gastric cardia
- Always add a partial fundoplication (Dor anterior preferred) to prevent reflux
- Intraop mucosal perforation must be recognized and repaired immediately
- Know type I vs II vs III achalasia and how it affects treatment choice
Common Curveballs
You notice a mucosal perforation during the myotomy
Repair immediately with absorbable suture. The Dor fundoplication will buttress the repair. If you miss it, the patient develops mediastinitis — this is a critical error that will result in a failing score on boards.
Patient has type III (spastic) achalasia
POEM is preferred for type III achalasia because it allows a longer myotomy extending proximally to cover spastic segments, which is difficult laparoscopically.
Postop barium swallow shows persistent bird's beak
Incomplete myotomy. The distal extension onto the gastric cardia was likely insufficient. May require reoperation or endoscopic balloon dilation.
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