Hellers cardiomyotomy

This is performed when achalasia is diagnosed. The addition of an anti reflux procedure is debated:

Pro They commonly suffer from reflux post operatively

Con An anti reflux procedure can cause dysphagia due to the poorly functioning oesophageal muscle.

Solution If you perform one a very loose wrap or incomplete anti reflux procedure should be performed.

Operation

A left antero lateral incision through the bed of the 6th or 7th rib.

The inferior pulmonary ligament is divided

The oesopahgus is mobilised from the inferior pulmonary vein to the diaphragm

A tape is passed around the oesophagus, and used to pull the OG junction into the chest so that the narrowed area can be seen

A scalpel with a large blade is used to divide the muscle down to the mucosa along the long axis of the oesophagus onto the stomach. 

DIATHERMY SHOULD BE AVOIDED TO REDUCE THE RISK OF MUCOSAL PERFORATION

A pledget is utilised to push back the mucosa for 50 % of the circumference of the oesopahgus

The use of an NG tube is debatable

An anti reflux procedure is debatable

Cross section post a partial Belsey wrap

Extended myotomy

This is indicated for diffuse oesophageal spasm, and consists of a myotomy upto the level of the aortic arch, otherwise it is similar to a Heller's procedure.