Laparoscopic Heller Myotomy with Partial Fundoplication
Updated On: July 23, 2026
Anesthetic Approaches
Aspiration risk - the defining problem of the case. The achalasic esophagus is an obstructed reservoir above an unrelaxing sphincter, so it can hold food and secretions from previous days however long the patient has fasted. Treat every one as a full stomach regardless of the documented fasting interval.
Preop history - because the reservoir overflows when the patient lies flat, ask specifically about nocturnal regurgitation, waking up with food on the pillow, and any treated pneumonia.
Pulmonary reserve - those symptoms mean months of microaspiration and possibly reduced reserve going into a pneumoperitoneum case. Ask what they last swallowed and when, not just when they last ate a meal.
Induction - rapid sequence induction with the head up and a working large-bore suction in your hand before you push drugs. Head-up positioning uses gravity to keep the passive column below the cricopharyngeus while you secure the airway, since there is no sphincter tone protecting you at either end.
Esophageal decompression - after the tube is in and the cuff up, pass a large-bore orogastric tube and suction the esophagus and stomach empty before the surgeon starts, which also makes the hiatal dissection safer. It comes out before intraoperative endoscopy, so coordinate removal rather than fighting the scope.
Depth of block for the myotomy - the surgeon is dividing muscle fibers millimeters off bare mucosa, so a single diaphragmatic twitch perforates the esophagus. Maintain deep neuromuscular blockade through the myotomy and the leak test, and confirm it with quantitative twitch monitoring rather than clinical impression.
Capnothorax recognition - mediastinal dissection at the hiatus frequently breaches the pleura, and pneumoperitoneum CO2 then tracks into the chest as a rising peak inspiratory pressure, a falling saturation, and a rising end-tidal CO2 midway through the dissection.
Capnothorax management - tell the surgeon, add PEEP and raise the FiO2, and expect it to resolve when the abdomen is desufflated. Most of these never need a chest tube.
Positioning and pneumoperitoneum - split-leg or low lithotomy with steep reverse Trendelenburg drops venous return at the same moment insufflation raises intrathoracic pressure, so hypotension right after the surgeon tilts the bed is expected and is usually preload, not depth.
Leg positioning - check that the legs are supported without pressure behind the knee and that the patient is secured against sliding toward the foot of the bed.
Nothing blind down the esophagus - once the myotomy is made, the mucosa is exposed under a thin fundoplication. Any tube passed blindly after that point can go straight through it. Pass nothing beyond the pharynx after the myotomy without the surgeon asking for it and watching it go.
PONV prophylaxis - retching against a fresh myotomy and wrap can disrupt the repair, so prophylaxis here is mechanical protection rather than comfort. Use multimodal antiemetics, consider propofol-based maintenance, and decompress the stomach before emergence so the patient does not wake up over a distended fundus.
Emergence - the aspiration risk does not end with the operation. Extubate awake with airway reflexes fully back and neuromuscular blockade completely reversed and objectively confirmed, and sit the patient up. Keep suction on the bed through transport.
Laparoscopic cases (general considerations): The patient's peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen. General anesthesia, ETT tube, and paralytics are necessary. Some of the procedures are rather short, so make sure the timing is right to reverse the paralytic. The pressure in peritoneum affects the organs of that space. Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS). Reduced blood to the kidney means reduced urine output. Peak inspiratory and plateau pressures will also increase. The gas used to insufflate the peritoneum is CO2 – so, as you might guess, hypercarbia can develop – and with it, acidosis. You'll see this sometimes reflected in the end-tidal CO2. This is all adding to the stress response we try to avoid in anesthesia.
Reverse Trendelenburg Position (general considerations): Improves access to the organs of the upper abdomen. To avoid patient slipping, use a foot board if an extreme angle is used. This position results in blood pooling in the abdomen and lower extremities. Reductions will be seen in stroke volume, cardiac filling, and cardiac output. The greater the angle, the greater these affects. Increases will be seen in FRC and compliance, which will be especially the case with obese patients. Ulnar nerve injuries can result if pressure is placed on the ulnar groove at the elbow. Any bump, rise, or IV pole along on the arm board between the elbow and the shoulder can result in radial nerve injury. Pad all pressure points (emphasis on head, sacrum, elbows, and heels) and ensure any straps used to secure limbs are loose enough to allow normal blood flow. Ensure the patient is not lying on IV tubing, monitor lines, or knots.
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
Achalasia is loss of the inhibitory ganglion cells in the myenteric plexus of the distal esophagus. Without them the lower esophageal sphincter (LES) never fully relaxes and the esophageal body loses coordinated peristalsis, so the gastroesophageal junction becomes a functional obstruction that nothing pushes through. The esophagus above it dilates over years into a passive reservoir that collects saliva, undigested food, and pills, and empties only by gravity and overflow. Patients present in their 20s to 40s with dysphagia to solids and liquids, regurgitation of undigested food, nocturnal cough, and weight loss. Manometry defines three subtypes and drives treatment choice. Chagas disease produces an identical picture and is worth asking about in patients from endemic regions. The retained column, not the sphincter, is what makes this case dangerous.
Setup - five upper abdominal ports, surgeon standing between the legs, steep reverse Trendelenburg so the viscera fall away from the hiatus. A liver retractor lifts the left lateral segment off the gastroesophageal junction.
Hiatal dissection - the phrenoesophageal membrane is opened and the distal esophagus is mobilized several centimeters up into the posterior mediastinum to expose enough muscle for the myotomy. Short gastric vessels are divided if a posterior wrap is planned.
Myotomy - the longitudinal and then circular muscle layers are divided down to bare mucosa, roughly 6 cm up the esophagus and 2 to 3 cm onto the gastric cardia. The gastric extension is the part that actually relieves the obstruction and the part most likely to buttonhole the mucosa.
Intraoperative endoscopy - a gastroscope is passed to confirm the myotomy crosses the full length of the high-pressure zone and that the scope now slides freely through the junction.
Leak test - the field is flooded with saline and the esophagus is insufflated endoscopically, or methylene blue is instilled, looking for bubbles or dye from a mucosal breach. A recognized perforation is repaired on the spot; a missed one becomes mediastinitis.
Partial fundoplication - a Dor (anterior 180 degree) or Toupet (posterior 270 degree) wrap is built to cover the exposed mucosa and limit reflux. A full 360 degree Nissen is avoided because an aperistaltic esophagus cannot generate the pressure to push a bolus through it.
Closure - ports are removed under vision and infiltrated with local anesthetic. Most patients start liquids on postoperative day 1 and go home the next day.
Peroral endoscopic myotomy (POEM) is the endoscopic alternative and increasingly the competing operation. It is done with the same full-stomach precautions and general endotracheal anesthesia, but it involves esophageal CO2 insufflation into a submucosal tunnel, so capnoperitoneum, capnothorax, and capnomediastinum are more common and can present as sudden high airway pressures or a tense abdomen. It does not include a fundoplication.
Robotic-assisted Heller is common at high-volume centers. The anesthetic is the same, but once the robot is docked the patient cannot be repositioned and you lose easy access to the airway and arms, so confirm line access, tube security, and eye protection before docking.
A small number of these convert to open laparotomy, usually for dense adhesions from prior pneumatic dilation or botulinum injection, or for a perforation that cannot be repaired laparoscopically. Ask preoperatively about prior endoscopic treatment, since it makes the planes worse and raises the conversion risk.