Laparoscopic Heller Myotomy and Partial Fundoplication for Achalasia
Main Text
Table of Contents
The gold standard for achalasia is surgical correction via laparoscopic Heller myotomy with a partial fundoplication. The goal of this technical report is to illustrate our preferred approach to patients with achalasia and to provide the reader with a detailed description of our operative technique, its rationale, and our preoperative and postoperative management.
Achalasia is a rare disorder of the esophagus, with an incidence of 0.5–1.2 in 100,000 cases/year, where the esophageal peristalsis is absent and the lower esophageal sphincter (LES) fails to relax, therefore causing dysphagia.1 This condition appears to be largely equally distributed among different races and gender groups. Some studies point to a bimodal age distribution, with peaks at 30 years of age and 60 years of age, while others indicated that the incidence of achalasia increases with age.
The most common presentation is dysphagia and regurgitation.2 Diagnosis is confirmed with barium esophagogram, upper endoscopy, and esophageal manometry. Manometry is the gold standard and usually shows failure of the LES to relax and complete loss of peristalsis. More refined diagnostics, such as the high resolution manometry (HRM), can identify variants and guide management based on predictable responses to medical and surgical treatments.5
Pneumatic balloon dilatation of the LES is a common approach to achalasia.6,7 However, there is a high rate of recurrence for which Heller myotomy (LHM) with a partial fundoplication is a more definitive management. Newer techniques, such as the peroral endoscopic myotomy (POEM) are emerging but their performance as compared to the LHM is still to be determined.8,9
LHM with Dor fundoplication is first-line surgical treatment of achalasia. Megaesophagus, defined as esophagus greater than 6 cm in diameter, is another esophageal pathology where studies have shown that LHM with Dor fundoplication provides excellent or good results in most of patients, even in those with a sigmoid shaped esophagus.3,1 0,11
The most common intraoperative complication of the LHM is an esophageal perforation. If the injury is recognized intraoperatively, then laparoscopic repair that includes closing the perforation with intracorporeal suturing using 4-0 absorbable sutures and a Dor fundoplication to patch the repair is sufficient. Risk factors for esophageal perforation are reoperation or previous Botox injections. If an esophageal perforation is suspected immediately postoperatively, then a water-soluble contrast medium swallow is recommended and a covered stent placed with an upper endoscopy and broad antibiotic coverage is sufficient in most cases. For late presentation of esophageal perforation, an Ivor-Lewis esophagectomy is the treatment of choice as this operation will remove all the diseased distal esophagus.
Persistent or recurrent dysphagia may occur after LHM. Persistent dysphagia may represent a technical problem with the myotomy or the fundoplication. Excessive narrowing of the esophagus can result from a short myotomy or a complete or near-complete fundoplication. Most of these cases can be corrected with pneumatic dilatation first, even though a wrong choice of fundoplication may warrant reoperation.
Recurrent dysphagia is defined as dysphagia that recurs after a period in which the patient has no symptoms. Recurrent dysphagia should raise concern for esophageal cancer, thus an upper endoscopy should be an essential part of the work up.13,14,15 If endoscopy rules out a malignancy, then one can offer the patient a pneumatic dilatation and a re-do LHM if this fails.16,17,18 An esophagectomy is the last resort after failure of all other treatments.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
- O'Neill OM, Johnston BT, Coleman HG. Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol. 2013;19(35):5806-5812. doi:10.3748/wjg.v19.i35.5806.
- Fisichella PM, Carter SR, Robles LY. Presentation, diagnosis, and treatment of oesophageal motility disorders. Dig Liver Dis. 2012;44(1):1-7. doi:10.1016/j.dld.2011.05.003.
- Willis T. Pharmaceutice rationalis sive diatribe de medicamentorum operationibus in humano corpore. London: Hagae-Comitis; 1674.
- Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22(9):e256-e261. doi:10.1111/j.1365-2982.2010.01511.x.
- Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas PJ. Achalasia: a new clinically relevant classification by high-resolution manometry. Gastroenterology. 2008;135(5):1526-1533. doi:10.1053/j.gastro.2008.07.022.
- Sweet MP, Nipomnick I, Gasper WJ, et al. The outcome of laparoscopic Heller myotomy for achalasia is not influenced by the degree of esophageal dilatation. J Gastrointest Surg. 2008;12(1):159-165. doi:10.1007/s11605-007-0275-z.
- Weber CE, Davis CS, Kramer HJ, Gibbs JT, Robles L, Fisichella PM. Medium and long-term outcomes after pneumatic dilation or laparoscopic Heller myotomy for achalasia: a meta-analysis. Surg Laparosc Endosc Percutan Tech. 2012;22(4):289-296. doi:10.1097/SLE.0b013e31825a2478.
- Inoue H, Minami H, Kobayashi Y, et al. Perioral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265-271. doi:10.1055/s-0029-1244080.
- Ren Z, Zhong Y, Zhou P, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc. 2012;26(11):3267-3272. doi:10.1007/s00464-012-2336-y.
- Liebermann-Meffert D, Allgöwer M, Schmid P, Blum AL. Muscular equivalent of the lower esophageal sphincter. Gastroenterology. 1979;76(1):31-38. doi:10.1016/S0016-5085(79)80124-9.
Cite this article
Marco Fisichella, MD, MBA, FACS. Laparoscopic heller myotomy and partial fundoplication for achalasia. J Med Insight. 2024;2024(18). https://doi.org/10.24296/jomi/18Procedure Outline
Table of Contents
- After a rapid sequence intubation, a nasogastric tube and a urinary Foley catheter are placed.
- The patient is then positioned supine, propped with surgical beanbag to allow the patient to be placed in a steep reverse Trendelemburg.
- The legs are placed in the semilithotomy position on stirrups. The surgeon usually stands between the patient’s legs and the assistant on patient’s right side.
- Trocar Placement
- Anatomical landmarks such as the xiphoid process and bilateral costal margins are marked prior to insufflation. A 1-cm transverse incision at the midline, two-finger breadths superior to umbilicus, is made for placement of Veress needle and abdomen insufflation.
- Once the abdomen is insufflated to a pressure of 15 mmHg, the optical trocar is placed to accommodate a 10-mm 30-degree laparoscope.
- Two operating trocars (11 mm each) are placed 2–3 cm below the right and left costal margins at the level of the midclavicular line.
- A 5-mm incision is made immediately to the left of the xiphoid process for placement of a Nathanson retractor. The retractor is positioned to expose the gastroesophageal (GE) junction by mobilizing the hepatic left lobe laterally and superiorly.
- Another 11-mm trocar is placed at the level of the left anterior axillary line and the transverse umbilical line.
- After all ports are positioned, the patient is placed in steep reverse Trendelenburg position that allows an optimal exposure of the GE junction by allowing all organs to fall downwards.
- Identification and Division of Gastrohepatic Ligament
- Control and divide accessory left hepatic artery if present.
- Separation of Right Crus of Diaphragm from Esophagus
- Identify posterior vagus nerve.
- Excision of Esophageal Fat Pad
- Dissection started just proximal to first branch of left gastric artery.
- Division of Peritoneum and Phreno-Esophageal Membrane
- Identify anterior vagus nerve.
- Dissection of Left Crus of Diaphragm to Junction with Right Crus
- Division of Short Gastric Vessels
- Mobilization of Esophagus within Mediastinum
- The gastrohepatic ligament is divided to expose the right pillar of the crus. An Allis clamp is placed at the GE junction to allow lateral traction and facilitate the blunt dissection of the esophagus from the right crus.
- An accessory left hepatic artery may be encountered at this point and safely transected.
- The esophageal fat pad, in the anterior abdominal esophagus, is transected to expose the angle of His, which will provide exposure needed for the cardiomyotomy.
- Cardiomyotomy consists of dividing the longitudinal and circular muscle fibers until outpouching of the submucosa is seen, with care not to perforate the submucosa. This dissection can be accomplished with the hook cautery.
- The dissection starts at the GE junction where the anatomical landmarks of the longitudinal and circular muscle fibers are most consistent, and extended cranially for about 7 cm.
- Then the myotomy is extended downward 3 cm onto the stomach up to the first branch of the left gastric artery. The gastric extension of the myotomy is often the most difficult part of the operation, because it entails in dividing the clasp (or U) fibers first described by Lieberman-Maffert.10
- The anterior and posterior vagus nerves are identified and preserved throughout the dissection, frequently reassessing their course in the stomach wall.
- The cardiomyotomy is performed onto the right anterolateral aspect of the esophagus, at the 10-o’clock position, between the anterior and posterior vagal nerves.
- It is started proximal to the GE junction and extended 6 cm proximally and 2.5–3.0 cm distally onto gastric wall.
- Muscles edges are separated by blunt dissection to expose mucosa.
- Although a Toupet fundoplication is a good alternative, we prefer to perform a Dor fundoplication as studies have shown similar outcomes. Hence, the fundus is freed by taking down the short gastric arteries using the access from the left upper quadrant.
- Then a left row of sutures is placed that encompasses the anterior wall of the stomach and the left edge of the myotomy. The uppermost stitch includes the apex of the left pillar of the crus.
- Next, the gastric fundus is folded over the myotomy and sutured superiorly along the diaphragmatic hiatus and medially along the right edge of the myotomy with 2-0 silk interrupted sutures. This completes the 180-degree Dor fundoplication.
- Left suture row:
- 1st suture incorporates fundus, left esophageal wall, and left crus.
- Other two sutures incorporate fundus and left esophageal wall.
- Fundus of stomach folded to expose mucosa.
- Right suture row:
- Three sutures incorporate fundus and right crus.
- Two more sutures incorporate fundus and esophageal hiatus.
- Evaluate for Perforation of Myotomy
- Removal of Trocars
- Immediate care: before extubation, the Foley and nasogastric tube are removed.
- Postoperative day 1, the patient is given a regular diet.
- Imaging of choice is a water-soluble contrast medium swallow radiography if there are concerns for esophageal perforation; otherwise, no imaging is usually needed.
- Postoperative follow up is done 1 week after discharge.
- Screening: this operation does not remove the risk of esophageal squamous-cell carcinoma (SCC) or gastroesophageal reflux resulting in development of adenocarcinoma. Therefore, upper endoscopic screening every 3–4 years is usually recommended. Recurrent dysphagia merits upper endoscopy evaluation to rule out malignancy.
- Patient seen in clinic two weeks after discharge.
Transcription
CHAPTER 1
So this one here is the xiphoid process, umbilicus. We're gonna put the the first port. Usually, the optical port is one inch above the umbilicus or fourteen from the xiphoid process. Okay? So more or less somewhere here. Because we're gonna put the patient in reverse Trendelenburg usually the mistake is that we put the pores too low. Okay? But this one here is like this, like fourteen centimeters or a fist. Okay? You wanna have at least a fist from, like, which is ten centimeters from each port. Okay? So they're gonna put this other port, this one here at the costal margin and the costal margin. One here, which is below the left costal margin at the level midclavicular line. Okay? Then we're gonna put the liver retractor over here. Another one - another another trocar here. Okay? Because that's the way one is supposed to work. Okay? So you can have this angle between here and here to the gastroesophageal junction. Okay? And then this one here is the optic, and then we're gonna put another one, which is same line, a kind of transverse umbilical line more or less, up to here laterally at the junction between this line and the anterior axillary line. That's it. Okay? Now, you see that there is the the incision here. We don't know if there are any adhesions below. So the teaching is that we're gonna put the first trocar as far away from the incision. So we're gonna put it here. Okay? And that's how we're gonna do it. Knife, fifteen. And then you use the Veress needle. Yes. Now, this one here, there's a technique. It's like a scratching - scratch. So you push and you scratch. Push and you scratch. Okay. And you scratch. Okay? And so you can feel actually the - the - no, don't worry about this. And you can feel, it... Going through the fascia? Going through the fascia. Yes. Scratch. Scratch. Uh-huh. Scratch. Gas? Yeah. Should be good, right. Oh, come here. Okay. First number is 11, 9. Second one is 8 - 0.8, and 0.7. Yep. So the first one here is 0.6. It's the intra-abdominal pressure. Okay. Which is set at 14 mm. The second one is the flow. Okay. Okay? And the third one is how many liters of of CO2 are inside the belly. I see. Okay. Usually, it's between, two and three. Maybe three and a half. But, then the left one is set on fourteen. The higher you go, the higher the chance the CO2 will go into the veins and cause a pulmonary embolus. So what's the good number for intra-abdominal pressure? Fourteen. Yes. Oh, fourteen. And then the flow is 0.5 or sometimes is right now, but usually it's between 1.2 and 1.5. Okay. The rate limiting factor is this thing. Remember the law of position? Uh-huh. It's longer and short in diameter. That's it. If you give him a trocar, look how big it is. Yeah. To get the intra-abdominal pressure at target will take, you know, ten seconds with this, but it's gonna take one minute with this guy here. I see. Because the radius.
No. No. Hold on. Yeah. Put it in put it in there. Good. Can I have the - this guy? Yes. Okay. Costal margin. I try to go below the costal margin. Okay. If not, it goes into the chest. And I try to angle upwards. Okay. More than just... Yes. The opposite. Okay. Can you switch to the thirty? Sorry. Yeah. The forty-five or thirty. Okay. Marguerite, I'm making a skin incision here. Look at that. You can see. Straight down. Yeah. What it works is your shoulder. Perfect. So you don't overshoot. Nice. Okay. Perfect. Here we go. Perfect. Let's get it connected then. Mhmm. Okay. It's tight. Perfect. Mhmm. I'll leave it there. Okay. Local to me. Sure. Can I make a stab incision there, Margarita? Accalasia. Accalasia. Okay. We gotta put the one here. Oh, I just wanna sit down. I'm gonna go with the slowly. Yep. Okay. Mhmm. Push right there. It's down here in the way. Uh-huh. It's okay. Don't worry. Push because if not, it's gonna go into the liver. It's okay. Like this, push like that. Perfect. Find the... Yes. You see? That's exactly what I want. Okay? Yeah. Okay. Okay. Right there. You see? Knife. Yeah. Can we have light off, please? This one here is the left lobe of the liver that has been retracted laterally. Okay? That is the the lateral portion of the left lobe of the liver. Okay? This one here that you see, this one here is the lateral portion of the left lobe of the liver. That's the left lobe of the liver, and this one here is the falciform ligament. You see? Yes. Perfect. Okay.
This one here is a ligament that goes from the liver. Okay? To the stomach. So it's called the hepatogastric ligament. Okay? It's very tiny and flimsy. You see if you lift it up. Yeah. Okay? You can see in transparency the first lobe of the liver or the caudate lobe, segment number one. These guys are here, these branches are branches that go from the anterior vagus nerve, which is right here to the gallbladder and the liver. You see? Okay. Right. We can cut them. There is no problem in doing this. Okay? This one here is a small phrenic vein. Okay? This one here is the triangular ligament. See? It's a shape of a triangle. Okay? This one here, the the esophagus is right here. You can see. Okay. Mhmm. And that's the stomach. The greater greater curvature of the stomach and the omentum, you see? The spleen is right on top. You see the spleen? Okay. That's a greater curvature of the stomach, a greater curvature, greater curvature. This one here pulsating is the right, the left and the right gastroepiploic that go all the way up to here and on top. Okay? This one here is the lesser curvature, It's right there. Perfect. Then you go to the pylorus, to the antrum here first, and then the pylorus you can't really see because it's somewhere over there, plaster. Okay? That's it. Perfect. So we're gonna grasp the anterior wall of the stomach right below the GE junction, and you tent it up. Okay? So the operation, you start by taking down the hepatogastric ligament. This one here becomes the phrenoesophageal membrane.
And we're gonna go from the apex of the left pillar of the crus, apex to the right pillar of the crus, to the apex of the left pillar of the crus. Okay? One second. Yeah. Like this. Like that. Oh, okay. Okay. Pick up with the camera. Okay. Come closer here. You're not there. Okay. This one here is esophagus. This one here is the right pillar of the crus. Yeah, but... Oh, man. Hold on a sec. Can I have a RayTech? Open RayTech. Yeah. I couldn't get it tight enough. No. No. No. Just open open it up. I couldn't get it tight enough. That's the easiest part of the operation. So this one here, it's one part of the muscle. You can see the other one. Just the muscle are so close. The left and right pillar of the crus? Seams. They're so close. They may not be right. Okay? One second. Okay. Let go for a second. Uh-huh. You pull down this. Okay. Pull. Pull. Uh-huh. Go out here. The plane that we cannot see on the other one, the other side, is right here. Mhmm. So, here. Okay. Back up. Back up with the camera. Mhmm. And go on this side here. You were on the wrong plane. Okay. But it's very weird anatomy. So that's the right pillar of the crus. We are basically stripped from the peritoneal, and that the crus - the other crus is somewhere in there. Mhmm. Okay? And there we're not too much. Okay. Pick up. No. Center here. Center like this. Okay. Come closer. Pick up for a second. Pick up. Margarita, hold it. Hold it. Put it in there. Uh-huh. Grasp the other part here. Grasp it now? Down. Down. Right. Right. Right. Right there. Grasp it right there. Grasp - look. Grasp the stomach. Right here. Right here. Uh-huh. Perfect. Pull up. Perfect. Stop it like that. Lower it? Lower? Yeah. Come - come, higher. Can you put one jaw in the hole? Okay. Yeah. Let go. Open. Put one in the... Hold it. Perfect. Close. Okay. Pull down towards you. Okay. Okay, back up. Hold this guy. So, this one here is pancreas. Okay? Okay. Right here. Back up. Close over there. Closer. Here's the last. Closer. There's a last... Go. Okay. Okay. Go more. Margarita. Okay. So now now what we did is this. Just liberated, freed the entire... So, it goes on the other side. Okay? So there is still some part missing there. This one here, you can see that's angle of His. Okay? And this one here is the - the center, center, left. Okay. No. This one here is the GE junction fat pad.
Let go. In there. That's the angle of His. From here. Okay. So this one here is the right pillar of the crus. This one here is the left pillar of the crus. The goose is in the middle right here. Okay. Yeah. That's a lot of dissection there. There's still some part that it is undissected. This part here, we have to clean it up a little bit more. That's the posterior vagus right there. Yeah. That's right. This guy there. Oh, nice. This guy. Okay? Yeah. Back up.
Controls are here. That's anterior vagus. Okay. Yes. You see the... Right on top? Yeah. This guy. Back up. So I'll go in there and here. So that's the esophagus here on top and below. It's the vagus there. See? This thing? Yeah. Okay. That's the vagus. Come closer there. Okay. So that's the plane in the posterior mediastinum. Okay. And that's a vagus. Left vagus goes anterior. Okay. Make sense? Yep. See now the esophagus is right here. Okay. It's almost freed, but it's a lot there are a lot of adhesions.
Okay. So the vagus is right here. One second. Well, look at this. This one here is the His. Okay? Okay.
So that's where the GE junction is going to be. So we had to mobilize this guy even farther down here. Yeah. So the vagus is right there. You can see the GE junction that goes right here. See? Right here and right there.
You see this one here is the first gastric artery, the first branch of of the left gastric. You see? Goes from one side. Look now how big it is now. Yeah. You see? You see? Vagus is going right here on top, below. We try to clean it up as much as we can. The angle of His is right there. You see? Yeah. So we are we go back, left, left. Uh-huh. Closer. So we are one centimeter below down. Okay? Like two maybe two centimeters. Mhmm. Come closer. I'm touching the - yes, the vagus is going right here. Okay. Let's clean this up and see how big Right here. So now we're gonna go into the serosa. You do those, the longitudinal fibers, and you're gonna go into, transect those a little bit? Yes. Okay. Come closer? It's okay. Small little vessel. It'll be fine. So let's go below. See, there's the second vessel. We cut one, two, and there's the third. So we're fine. Look at that. We are here, one inch above. Bless you. Okay? This will flip it all the way up to there. And this is all the way up to here. Okay. Oh, sorry. That's your landmark to know how... Yes. Yes. Yes. That's why I don't use endoscopy. You see? So you can see clearly, this one here is the first or the second. I think the first was here. Right there. Okay? And the second or maybe this one here is just the first. Just the first branch. Okay? Which is - the angle of His is right here. So it's at least one inch. Okay? Two to three centimeters. Below. See that's a marker. Yes. I see, great. Yes. This one here is the second guy. You see? We can basically cut. You see? But this one here is the is the esophagus. See? From here to here. Okay. See? That's the second branch. Okay. Look how big it is now. From here to there. Okay. Now let's clean it up. So where do we start the myotomy? Always on top. Okay. Okay. Come closer.
CHAPTER 2
Okay. You see the thing that is pushing out? Yeah. That's a... That's a submucosa. Yeah. Submucosa. Uh-huh. Okay. Let me show you this. Okay. Then you get the center. Center. Center. Okay? So that's the submucosa. Okay. So once you get in that plane... Yes. But you gotta be careful not to burn the submucosa. Okay. Our explosion. Go to the myotomy. Now you see the myotomy really nicely. See? See the circle of fibers now become oblique? Look at that. We are there. And this one here is oblique. I see. See? These link fibers. Which is okay. We are very far away from the submucosa, so... So let me stop for a second. So we are pulling the the esophagus down. Theoretically, this operation could have been done from the chest by opening or just the - these small two little incisions. That's how Ellis did it. But no one has been able to replicate the paper of Ellis. Only him. Okay? So what people do is say, okay, let's go from the belly, but we'll do it in - we'll do it from the belly, but we'll we'll go down in the, in the GE junction and in the stomach. Okay? Okay. Let's go in. Can you see the myotomy there? Okay. Right here? Perfect. So angle of His right here. We're here, and we are look how far down we are. Okay? So look at this, the GE junction is here. You see? It's right there. See that it curves? It curves. Oh, yeah. Okay? And it goes right there. Make sense? So it's right here. Mhmm. This one here it's all opened up. Make sense? Yeah. Right. Okay. So this one here is the portion of the mucosa. This one here is the other part of... Go right here for a second. No. You just yes. Towards me. Pull down towards you. Pull towards you. Oh, like that. Okay. That's it. I won't do - there's no other way you can go. Look at this, how big it is. Yeah. Come closer? Perfect. You see? Uh-huh. Let me see. Let me clean it up a little bit more. Apply some pressure there. So stop bleeding. Come closer. Okay. Okay. So now it's not linear anymore. Kinda. That's okay. That's humongous. See the GE junction? Hold on a second. Back up, back up, back up. See the GE junction there? Right here. See? Because he wants to connect with the other side. You see? I see. Yeah. One side, on that side. Makes sense? Yeah. Margarita. You see? Margarita. Yeah. I'm looking. This go here. Okay. Oh, I see. Okay. Okay. Okay. Now we need the Endo Stitch. Yes. Do you like it cut to a certain length or like it whole? Seventeen - uh, fifteen centimeters. So we've completed the myotomy. And then... Now we do the Dor fundoplication. The Dor. Mhmm. There's an anterior... Yes. But you see why we do the that - well, some people do the posterior wrap to keep the edges open. Oh, I see. Okay. Because you - and then you pull it open. This one here, do we need the endoscopy to find out that we have no perforation that we cut off this We cut all the the- there is no perforation. We don't need endoscopy. Did we cut all the circular fibers? You saw that. There is no circular fibers. Right. Are we below the GE junction? Yes. Because we saw it and we saw the markers. So there is no need for the endoscopy. That's the reason why I don't use it. Perfect. Just leave it there. Just leave it like this. Hold on like this. So is there a higher recurrence rate with the POEM? The what? With the POEM, is there a higher reference? I don't understand. With the endoscopic approach, is there a... Oh the POEM? Is there a higher recurrence of... We don't know because the studies are still too small. Can you get me closer? Stop right there. No, too close. Center here. Perfect. Because then we're gonna put a - see that? This one here, the short gastrics. Okay. Okay. So we're gonna put one here and here. One into the crura. And then one, two, and three to keep this open.
Okay? Oh, I see. Okay? So you're running one through the stomach, one through the crus, and one through that - through the new opening there. Endo Stitch. So through the serosa of the esophagus, right? Yes. So you start above the GE junction, then you go on the GE junction, then you go below. Yeah. Hold on a sec. Hold on a sec. Come closer. Yes. I'm trying to get this on the mucosa now. Yeah. Sorry. The... The serosa - the muscularis. Yes. So... One second. One second. One second. Come above me. Scissor? Hunter? Come closer. Okay. Hunter? Got it. Let me see how it looks. Okay. And then we're gonna fold it up like this. Oh, I see. Okay. Make sense? Yeah. Now so now you're going for the right crus? Yes. Now we're going - that's the first stitch got the fundus of the stomach, the apex of the left crura, and the left upper portion of the left edge of the myotomy. Yes. Okay? Now we're gonna do the same thing here and here. So there are three - there are two rows of sutures. The first row is the left one. The first one gets the fundus of the stomach, the apex of the crus, and the myotomy. The second and the third get the - the stomach and the myotomy, the stomach and the myotomy. Then we'll fold it over. And the edge of the - this guy here - the short gastrics - will get the myotomy only. If you put myotomy, myotomy, myotomy. Eventually, the first stitch we can put the first one. You see? But if we - if we put the stitches around here, you will tent up the - this one here too much. See? Too much and now you see the patient can't swallow. Makes sense? Because this one here is too tight. Okay? But if you put it here, it's gonna be fine. Okay. This one here is gonna function like a myotomy and also is gonna function as a new valve for the - do you remember I showed you the picture? Yeah. Yeah. That's right. Okay. Okay. The ledge of - the edge of the myotomy. Yeah, show me, Margarita. Okay. These things serve to keep the myotomy open. If not, we're gonna - some people say that if you do - a Dor, eventually, the the two edges get scarred down and they approximate and the patient have recurrent dysphagia and need to have another operation. So this one here, through the myotomy and through the crus. Through the myotomy, and through the crus. Mhmm. Mhmm. Flip it over, my friend, right here. Uh-huh. It's okay. Perfect. You got it. Let go. Let go. Let go. See that there is no stitch or a cross. Okay. Can I have a stitch? We need, after this, one more. Okay.
CHAPTER 3
[No dialogue.]