Heller's myotomy for achalasia was originally performed with two separte incisions in the esophagus. Today most surgeons advocate a single incision. The myotomy extends for at least 5 cm in the lower esophagus onto the gastro-esophageal junction. Some surgeons prefer the myotomy to extend more proximally into the esophagus. It is felt that if the myotomy extends too far onto the stomach that the patient will develop severe gastroespohageal reflux, so many surgeons limit the extent of the myotomy distally.
Some surgeons resect some of the muscle of the esophagus as a strip others just do a myotomy and separate the submucosa from the muscle on each side of the incision.
To reduce the chances of reflux some surgeons advocate a fundo-plication. The stomach may be sutured onto the edges of the myotomy, this has a dual function. Firstly it will reduce reflux and, secondly, it will reduce the chances that the myotomy will heal and the dysphagia return. The fundoplication that is used is different from that used in anti-reflux surgery (Nissen's). The esophageal muscle does not work well in achalasia and a full fundo-plication will cause dysphagia even if the lower esophageal sphincter is completely divided thus the partial fundo-plication. The partial fundo-plications that are often done following the myotomy in achalasia are the D'Or procedure or the Toupet.
The myotomy can be performed from the chest or from the abdomen, and either using conventional open surgery or minimally invasive laparoscopic or thoracoscopic techniques.
Following a successful myotomy the patient will usually gain relief from their symptoms, however, they will deteriorate with time and many will have recurrant symptoms after 15 years.