Heller Myotomy with Dor Fundoplication
Heller myotomy is a surgical procedure to relieve the obstruction between the esophagus and stomach by dividing the muscle layer from the esophagus down to the stomach. It is used to treat achalasia. One of the side effects of Heller myotomy is the development of reflux. In order to prevent reflux, Dor fundoplication is performed at the time of surgery.
We use the most advanced robotic system called Da Vinci Xi to perform Heller myotomy with Dor fundoplication The name of the procedure is “Robot-assisted laparoscopic Heller myotomy with Dor fundoplication.” We perform the procedure through five small incisions in the abdomen. We separate the esophagus away from the diaphragm, divide the muscle overlying the esophagus and the stomach, and partially wrap the esophagus with the upper portion of the stomach or fundus of the stomach.
In order to ensure that the myotomy adequately relieves the obstruction and the Dor fundoplication is not too tight, we use a balloon called an Endoflip to tailor the operation. This is performed during the operation. The balloon catheter is placed through the mouth into the stomach and the esophagus and removed at the end of the operation.
Overall, the risks of the operation are very low. With any operation, there is a risk of injuring any structure that we operate around including the esophagus, stomach, liver, spleen, vagus nerve, diaphragm and the pleura. Other risks include bleeding and infection at the site of surgery. There is always a risk of needing to convert from a small incision to a larger incision.
Hospital Stay: 1 Day
After the operation, the patient goes to a recovery area called PACU or post-anesthesia care unit. Once the patient recovers from anesthesia, the patient is admitted under observation on the floor. On average, patients are in the hospital for one night. Patients start a liquid diet during the night of the surgery along with pre-emptive pain control with around the clock pain medication. If patients can tolerate a liquid diet with good pain control, they are ready to continue the recovery at home.
At home, we ask patients to have a liquid diet for two weeks to prevent any vomiting episodes that would cause complications with the surgical repair. After two weeks, patients are asked to start a soft diet avoiding breads and tough meat such as steaks. When taking in a solid diet, it is very important to chew well and let the food pass down into the stomach before taking the next bite. If patients have too much difficulty with solid food, we advise patients to stay on a liquid diet for an additional week. You should be able to be back on a regular diet about four weeks after surgery.
We also advise our patients to stay ahead of the pain with pre-emptive pain control. Instead of taking pain medication after having pain, we ask patients to take pain medication in regular intervals. The typical regimen for post-operative pain medication is:
3 days of Aleve (Naprosyn) 1 tabs two times a day
5 days of Tylenol (Acetaminophen) 1 g three times a day
After 5 days, take Tylenol as needed. If this regimen is not adequate to control pain, we ask patients to call our office.
In order to further help with recovery from surgery, we advise patients to walk at least three times a day, work on the incentive spirometer, and sit in a chair for at least 6 hours a day for about a week after the surgery. We advise patients to avoid heavy lifting for 6 weeks. As long as the patient is not on narcotic pain medication, it is safe to drive.
One of the things that we want patients to avoid during the recovery period is being constipated. Constipation can cause an increase in intra-abdominal pressure that can put a strain on the repair. We recommend taking over the counter stool softener such as Dulcolex or Colace to make sure they have normal bowel movements.
A common side effect of this operation is bloating. This is caused when patients swallow air and it gets trapped in the stomach with a new barrier between the esophagus and the stomach. This usually gets better over time but in order to minimize discomfort, we ask patients to take Gas-X four times a day for 1 month.