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A fundoplication must be combined with myotomy to prevent acid reflux. Nowadays, there is controversial data in the literature between these techniques.
It is clear that the Nissen fundoplication is associated with a higher rate of obstructive symptoms, when its compared with a Toupet (260º posterior fundoplication) it has better functional outcomes. On the other hand, the Dor (180º anterior fundoplication) is technically easier, and covers potential zones of mucosal perforation.
In this video, you will see a laparoscopic Heller myotomy plus a Dor fundoplication for a patient with achalasia.
A total of five trocars were used, one of 12mm in supra umbilical position for a 30º scope, two of 11mm (one on each flank) and one of 5mm at the epigastrium and another more lateral at the left flank.
The first maneuver is to open the gastrophrenic ligament, dissect the crura and the distal esophagus, in order to identify the gastroesophageal junction and the left vagus nerve. A marked ribbon is used to set the limits of the myotomy (measuring 4 cm from the gastroesophageal junction to the esophagus and 2 cm towards the stomach).
A Foucher is placed to prevent mucosal lesions. The myotomy is performed with the hook, the longitudinal muscle layers were sectioned and then circular, careful maneuvers must be done at this phase of the surgery because the mucosa is under the muscular layer. Some surgeons may perform the myotomy with scissors.
The dissection of the stomach's wall is more difficult and must me done from up to down with the hook to improve control.
The next step is to prepare the fundoplication, the greater curvature of the fundus must be dissected sectioning the short vessel with the help of the LigaSure™.
Anterior plication of the stomach was made, first from the fundus to the esophagus with separate knots in order to maintain the myotomy openden and then from the fundus to the crura, to fixate the anterior valve.