A 43-year-old male patient came to polyclinic with complaints of the difficulty of eating, drinking, and weight loss. The patient came carrying oesophagomaagduodenography (OMD) results from the previous hospital with a diagnosis of suspected achalasia with a differential diagnosis of distal esophageal carcinoma. CT scan and endoscopic examination were performed and the results were within normal limits. The patient had a history of pulmonary tuberculosis treatment. Pulmonary disease is a contraindication for laparoscopy. Laparotomy finger-guided Heller cardiomyotomy with Toupet fundoplication was performed. The duration of the operation was 45 min with minimal bleeding. The patient was evaluated 2 weeks postoperative and showed that he could eat and drink without any complaints. 6 months after surgery the patient had a weight gain of 5-10 kg.
The authors attest that full and informed consent was obtained from every single patient who have undergone medical treatment in our Hospital. The informed consent form also declared that patient data or samples will be used for educational or research purposes. This work has been registered in the a publicly accessible database and having a unique identifying number : researchregistry4073.
First, we performed surgical procedure under general anesthesia.
We made an upper midline incision.
Then we did a general exploration of the abdomen while was paying attention to the esophagogastric junction;
We mobilized the left hemiliver by dividing the triangular ligament to expose the lower esophagus;
Then, we divided the small bands between the stomach and spleen to avoid tearing of the splenic capsule and divide the peritoneum over the esophagus, then retracted the stomach downward;
We divided the gastro-hepatic ligament, phrenoesophageal ligaments and excised the esophageal fat pad and crus medial and lateral diaphragm to allow downward mobilization of the esophagogastric junction;
A 1.5 cm incision at the gastric corpus was made andthen we inserted an index finger through the incision that has been made into gastric lumen, continued to esophagogastric junction, then into esophagus.We then felt the constricted (spasmodic) lumen.
With finger guiding, we divided all the circular and longitudinal muscle fibers to make the myotomy above the area of constriction until the esophageal mucosa is visible.
The myotomy incision was extended 4 cm into the esophagus and 2 cm into the gastric cardia to reduce outflow resistance.
The evaluation was done by feeling with the finger that the distal esophagus is loosened and the muscle spasm is released then we gave normal saline liquid through the nasogastric tube into the esophagus by closing the cardia area to ensure no mucosal leakage and the mucosa should have been seen bulged. The illustration of the technique is shown in Fig. 1.
Finger-guided Heller Cardiomyotomy Procedure: