Abstract
Background/Objective: Since 1996, both laparoscopic and thoracoscopic Heller myotomy, with and without fundoplication, have been described for the treatment of pediatric esophageal achalasia. Many pediatric surgeons have been hesitant to perform these procedures, primarily due to their technical difficulty and the difficulty (and expense) of coordinating continuous intraoperative flexible esophagoscopy with a willing (and available) pediatric endoscopist. We describe two recent technical modifications allowing a more rapid, controlled, safe procedure without the need for intraoperative esophagoscopy.
Methods: Three symptomatic children, ages 10–14 years (mean, 11.7 years), with esophageal achalasia documented by upper gastrointestinal radiographic series (UGI), flexible esophagoscopy, and manometry, underwent laparoscopic Heller myotomy using five 5 mm trocars and the 5 mm hook cautery. To guide the length and depth of the myotomy incision, a 6F Fogarty catheter was passed by the anesthesiologist through the mouth and into the stomach. Following inflation of the Fogarty balloon, the catheter was gently pulled back toward the distal esophagus, distending the cardio-esophageal junction and the esophageal lumen, allowing improved laparoscopic visualization of the myotomy length and depth as it was performed. A member of the surgical team then reached above the drape to grasp and manipulate the Fogarty catheter and therefore achieve both visual and tactile conformation of myotomy completeness. Following myotomy and division of the short gastric vessels using the harmonic scalpel, a Dor fundoplication was perfomed using the Suture Assist Device, with pre-tied knots.
Results: Surgical times varied from 116 to 197 minutes (mean, 150 minutes). Each patient was fed on postoperative day (POD) 1 and discharged to home on POD 1 or 2 following UGI. There were no esophageal leaks. Followup has ranged from 28 to 30 months. Each patient has had complete relief of preoperative symptoms.
Conclusion: Transoral placement of a 6F Fogarty catheter aids in the performance of laparoscopic Heller myotomy in children, obviating the need for intraoperative flexible esophagoscopy. In addition, use of the Suture Assist Device, with pre-tied knots, aids in the performance of laparoscopic Dor fundoplication in these patients. Since both the Suture Assist Device and the harmonic scalpel can be inserted through 5 mm trocars, use of 10 mm trocars, as previously reported, is no longer required.
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