Laparoscopic Hellers myotomy

Beanbag
Stirrups
20-30 Reverse Trendelenburg
Compression stockings
Stand between legs
Nathanson
Divide gastrohepatic ligament
Separate right crus from diaphragm with blunt dissection
transect peritoneum and phreno-oesophageal membrane
Separate left crus by blunt dissection
Continue into posterior mediastinum to expose 6-7cm of oesophagus
Identify and preserve anterior and posterior vagal divisions
Divide short gastrics all the way to the angle of His
Hook diathermy myotomy to submucosal plane 2cm down onto stomach to 5cm past GE junction
Avoid diathermy if bleeding encountered as can cause delayed perforation
If perforation suspected, intstil saline and blow air down orogastric, if found repair with 3-0 PDS
Combine with fundoplication
Ba swallow only if perforation suspected
Avoid meat or bread for 2 weeks