ACS Surgery: Principles and Practice

During the 1970s and the 1980s, operations for benign esophageal disorders were often withheld or delayed in favor of less effective forms of treatment in an effort to prevent the postoperative discomfort, the long hospital stay, and the recovery time associated with open surgical procedures. For instance, pneumatic dilatation became first-line therapy for achalasia, even though surgical management had been shown to be clearly superior.1 In the first part of the 1990s, it became clear that treatment of benign esophageal disorders with minimally invasive procedures yielded results comparable to those of treatment with traditional operations while causing minimal postoperative discomfort, reducing the duration of hospitalization, shortening recovery time, and permitting earlier return to work.2,3 Consequently, minimally invasive surgery was increasingly considered as first-line treatment for achalasia, and laparoscopic fundoplication was considered more readily and at an earlier stage in the management of gastroesophageal reflux disease (GERD). Since then, minimally invasive esophageal procedures have continued to evolve, thanks to better instrumentation and improved surgical expertise. In addition, with greater experience and longer follow-up periods, it has become possible to analyze techniques and their results more rigorously. For instance, whereas a few years ago a left thoracoscopic Heller myotomy was considered the procedure of choice for achalasia, the current procedure of choice is a laparoscopic Heller myotomy with partial fundoplication, which has proved to be better at relieving dysphagia and controlling postoperative reflux.4-7 Similarly, whereas total fundoplication and partial fundoplication were initially considered equally effective in treating GERD,8 total fundoplication is now viewed as clearly superior for this purpose and should be used whenever feasible.9 In this chapter, I focus on minimally invasive approaches to the treatment of abnormal gastroesophageal reflux and esophageal motility disorders.The standard open counterparts of these operations are described elsewhere [see 4:7 Open Esophageal Procedures].