Laparoscpic Oesophago-myotomy

1.Position the patient in lithotomy, reverse Trendelenberg.
2.There should be two monitors on either side of the head end of the table.
3.Camera port a third of the way above and to the left of umbilicus, xiphisternal Nathanson retractor on an Omnitract bar, 5mm ports in RUQ, two in LUQ.
4.You will also need extra room at the head end of the table for a UGI endoscopy setup.
5.Begin by mobilizing the oesophagus as for Lap Nissen, however attempt this with minimal posterior dissection. It will decrease the incidence of post-operative reflux.
6.Pass a grasper under the oesophagus across to the left of the oesophagus and bring a Penrose drain around to be used as a retractor, lengthening the segment of intra-abdominal oesophagus.
7.Find a convenient point in the middle of the thickened segment of oesophagus and divide with diathermy scissors.
8.Atraumatic graspers can then be used to pull down on the longitudinal muscle to reveal the underlying thickened circular muscle layer.
9.Similarly divide the circular layer and watch the layer spring apart. Atraumatic graspers are adjusted to hold the divided circular fibre layer.
10.The epithelial tube can be protected by pushing it down with a right angled grasper. Extend the myotomy proximally and distally (should extend 1cm on to the stomach) until the muscle appears to thin out.
11.Irrigate with saline and fill the LUQ. Insufflate the oesophagus with the endoscope and watch for any leaks.
12.Perform an anterior partial wrap (Dor) if there is a leak once repaired with interrupted 3/0 PDS or a partial posterior wrap as it is supposed to help keep the edges of the myotomy apart.
13.Close in layers.