Laparoscopic Cardiomyotomy — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Laparoscopic Heller cardiomyotomy (also called Heller myotomy) is a minimally invasive surgical procedure to treat achalasia — a primary oesophageal motility disorder in which the lower oesophageal sphincter (LES) fails to relax properly during swallowing, causing progressive dysphagia (difficulty swallowing), regurgitation of undigested food, and chest pain. The procedure divides the circular and longitudinal muscle fibres of the lower oesophageal sphincter and the upper stomach longitudinally, eliminating the functional obstruction at the gastro-oesophageal junction. First described by Ernst Heller in 1914 as an open procedure, it has been performed laparoscopically since the early 1990s and is now the gold-standard surgical treatment for achalasia worldwide. Because the myotomy weakens the LES and predisposes to gastro-oesophageal reflux disease (GORD), a partial fundoplication (typically Dor or Toupet technique) is routinely added during the same procedure to provide anti-reflux protection without impeding swallowing. The procedure is performed by specialist upper gastrointestinal or oesophageal surgeons. Laparoscopic Heller cardiomyotomy (Heller myotomy) is a minimally invasive surgical procedure to treat achalasia — a primary oesophageal motility disorder in which the lower oesophageal sphincter (LES) fails to relax properly during swallowing, causing progressive dysphagia, regurgitation, and weight loss. Achalasia affects approximately 1 per 100,000 population per year. It results from destruction of ganglion cells in the myenteric (Auerbach's) plexus of the distal oesophagus, causing LES hypertension and failure of deglutitive relaxation. Laparoscopic Heller myotomy, first performed laparoscopically in 1991, is the most durable surgical treatment for achalasia, achieving symptom relief in 85–95% of patients at 5 years. It is combined with an anterior partial fundoplication (Dor fundoplication) to prevent iatrogenic gastro-oesophageal reflux. The procedure is performed by upper gastrointestinal or general surgeons with laparoscopic expertise.

Laparoscopic Heller myotomy is indicated as the preferred definitive treatment for confirmed achalasia in patients who are fit for general anaesthesia. Achalasia diagnosis is established by high-resolution manometry (showing aperistalsis and impaired LES relaxation, integrated relaxation pressure >15 mmHg), supported by barium swallow (bird-beak sign at the LES) and endoscopy to exclude pseudoachalasia from malignancy. Patient selection favours surgery over endoscopic alternatives in: younger patients (below 50 years) where the greater durability of surgery over pneumatic dilation (PD) is most beneficial; patients who have failed previous pneumatic dilation; patients with sigmoid-type oesophageal dilation from longstanding disease; those with prior treatments affecting oesophageal anatomy; and centres with experienced oesophageal surgeons. Contraindications include end-stage megaoesophagus requiring oesophagectomy, significant comorbidity precluding anaesthesia, and active systemic infection. Peroral endoscopic myotomy (POEM) — an endoscopic alternative performed through the natural oesophageal lumen — offers comparable effectiveness to Heller myotomy and is increasingly available at specialist centres.

Under general anaesthesia, the patient is positioned supine with reverse Trendelenburg tilt. Five laparoscopic ports are placed in the upper abdomen. CO2 insufflation creates the working space. The oesophago-gastric junction and distal oesophagus are mobilised by dividing the phrenoesophageal ligament. The anterior vagus nerve is identified and preserved. The myotomy begins 6–8 cm above the LES on the distal oesophagus and extends 2–3 cm onto the gastric cardia below the gastro-oesophageal junction, ensuring complete division of all circular muscle fibres at the LES level — the most common cause of failure being an incomplete myotomy. The plane between the muscle layers and the submucosal plane is developed using blunt dissection and a hook electrocautery or ultrasonic dissector. A Dor fundoplication (anterior partial wrap, 180 degrees) is then fashioned by suturing the gastric fundus over the exposed mucosa, simultaneously protecting the mucosal closure and providing anti-reflux protection. Intraoperative endoscopy is performed to verify complete myotomy and mucosal integrity. Surgery takes 2–3 hours. Oesophageal mucosal perforation (1–3%) — the most significant intraoperative complication — is repaired immediately during the same procedure. Under general anaesthesia, the patient is positioned supine with reverse Trendelenburg tilt. Five laparoscopic ports are placed in the upper abdomen. CO2 insufflation creates the working space. The oesophago-gastric junction (OGJ) and distal oesophagus are mobilised by dividing the phrenoesophageal ligament and opening the oesophageal hiatus. The myotomy is created by incising the outer longitudinal and inner circular muscle layers of the distal oesophagus (extending at least 6 cm proximally) and the gastric cardia (extending 2–3 cm onto the stomach), using hook diathermy and careful blunt dissection to avoid mucosal perforation. Intraoperative endoscopy confirms mucosa integrity and adequate myotomy length by visualising the OGJ from inside. A Dor anterior partial fundoplication (180-degree wrap) is then constructed over the myotomy to reduce the risk of gastro-oesophageal reflux disease, which occurs in 30–40% of patients after myotomy alone. Total operative time is 60–120 minutes.

Laparoscopic Heller myotomy is the most durable single treatment for achalasia, achieving symptom relief (Eckardt score ≤3) in 85–90% of patients at 5 years and 75–85% at 10 years. Dysphagia improvement is typically noted immediately post-operatively. In comparative trials, Heller myotomy is superior to repeated pneumatic dilation at 10-year follow-up (90% vs. 65% symptom control) and equivalent to POEM at 5 years, though POEM has higher post-operative GORD rates without a concurrent fundoplication. The minimally invasive laparoscopic approach offers the benefits of a major surgical procedure — durable LES disruption under direct visualisation — while maintaining the advantages of a keyhole approach: small incisions, shorter hospital stay (1–3 days versus 5–7 days for open surgery), less postoperative pain, and faster return to work. Weight regain and nutritional improvement following restoration of normal swallowing are significant quality-of-life gains for patients who had progressive weight loss from achalasia.

The most serious intraoperative complication is oesophageal or gastric mucosal perforation, which occurs in 1–3% of cases and is repaired laparoscopically in the same setting. Unrecognised perforation requires conversion to open surgery. Post-operative gastro-oesophageal reflux occurs in 10–20% of patients who had a concurrent Dor fundoplication, and 40–60% without anti-reflux addition, monitored with pH-impedance testing at 3–6 months. Dysphagia recurrence from an incomplete myotomy or progressive LES scarring affects 10–15% of patients at 10 years. Conversion to open surgery is required in less than 2% of cases. Pulmonary complications (aspiration from retained oesophageal contents) are prevented by perioperative clear fluid diet, head-up positioning, and thorough endoscopic clearance before surgery. Long-term surveillance with annual endoscopy is recommended given the 10-fold increased oesophageal cancer risk in achalasia patients, particularly in longstanding untreated disease leading to oesophageal stasis and mucosal inflammation.

Hospital stay is 1–3 days. A sip-of-water trial is performed the morning after surgery to confirm safe swallowing. Patients progress from clear liquids to a soft diet over 2–4 weeks, then advance to a normal diet. The primary dietary instruction is to eat slowly, chew thoroughly, and avoid large food boluses to allow the oesophagus to accommodate while healing. Patients return to light work and activities within 2 weeks. Strenuous physical activity and heavy lifting are restricted for 4–6 weeks to allow port-site and fundoplication healing. Swallowing improvement is typically immediate after surgery, with patients often reporting dramatic relief from the dysphagia they had struggled with for months or years. Post-operative proton pump inhibitors (omeprazole or lansoprazole) are prescribed for 3–6 months and continued if reflux testing at 6 months confirms GORD. Failed myotomy — assessed by persistent or recurrent Eckardt score >3 — can be managed with repeat pneumatic dilation, POEM, or in severe cases, oesophagectomy.