Heller's myotomy, (a type of myotomy, cardiomyotomy and esophagocardiomyotomy), is a surgical procedure to improve swallowing in patients with a disorder called achalasia. A myotomy is the cutting of muscle. A Heller myotomy makes a cut in the ring like muscular valve at the junction of the esophagus and stomach known as the cardia or lower esophageal sphincter (LES). In achalasia the patient has problems swallowing because the LES remains contracted and fails to relax properly to allow food to pass into the stomach and the contractions in the esophagus that push food down, peristalsis, are dysfunctional or otherwise unable to push the food through the LES. Cutting the LES weakens it allowing food to pass through the constricted LES.

Ernest Heller first performed it in 1913. In the past it was done using an open procedure through the chest (thoracotomy) or the abdomen (laparotomy). Today it is sometimes still done open but more often is done using minimally invasive endoscopic techniques, mostly laparoscopic (abdomen) but also thoracoscopic (chest) techniques. These techniques can even be done robotically and very precisely. laparoscopic, minimally invasive surgery, also known as bandaid surgery, or keyhole surgery, uses only about five or six very small incisions, about half an inch or less (0.5 - 1.5 cm), through which instruments are inserted to perform the myotomy. Often the patient is able to return home the next day, instead of after a week or so as with an open procedure.

Laparoscopically, the procedure is done while the patient is under general anesthesia. The abdomen will be filled with gas to inflate it and so provide room to view the abdominal cavity from within. A scope or camera will be inserted to provide the view. An incision is made from a point on the esophagus a little above the LES to a point on the stomach a little below the LES. The length of the incision depends on the technique and whether a partial fundoplication (wrap) is going to be included in the procedure. The incision cuts completely through the outside muscle layer but not into the mucosal layer. After the myotomy the surgeon checks to see if any of the incision went through the mucosal layer to cause a perforation, which could cause the esophagus to leak, causing a potentially life threating condition. Any perforations found are repaired. The risk of a remaining leak is small but must be considered. After the surgery, usually the next day, a barium swallow is performed to check for any leaks that were missed and to judge the success of the surgery.

If the LES is not weakened enough the surgery may not provide enough improvement of symptoms. If the LES is weakened too much stomach acids may reflux through it causing heartburn and damage. Long-term acid reflux may even lead to esophageal cancer. For these reason some surgeons prefer to make sure the myotomy is long enough to provide clearance for food and then add a procedure called a fundoplication where part of the stomach is "wrapped" around LES to prevent acid reflux. How long to make the myotomy, whether to do a fundoplication and which fundoplication is best, have all been the subjects of controversy and surgeons differ in their opinions and techniques. Surgeons also differ in opinion on the need for follow up after myotomy. Some require patients to return at regular intervals over the years to screen them for developing problems while others only require seeing their patients after recovery if there are problems.

While recovering at home the patient will be on a liquid or soft food diet and limited to how much the patient can lift. In two to three weeks the patient often returns to work, depending on lifting, and begins eating a normal diet. Recovery time can be much longer for open surgery. Often the stomach may seem small and quickly full. Over time the stomach will stretch.


A good surgeon who is well experience with this procedure, and has an experienced hospital team, can have an 80 - 90% success rate. It is not just his experience and skill in general that matters. Skill with this specific procedure is important and most surgeons will have few if any chances to try it. Skill for the surgery can improve even after many have been performed. In the USA there are only about 2000 - 3000 new cases of achalasia each year. Not all of those will even have myotomies. Many patients will use other treatments, if any. So, to have a surgeon that has the skill acquired by doing many Heller myotomies patients often travel long distances to top medical centers and teaching hospitals. That is especially true for children who are much rarer than adults with achalasia and require special skills.

There is no cure for achalasia and the myotomy is just to relieve symptoms. Even with the best surgeons a Heller myotomy may not be a success for every patient. In some patients the esophagus may be too dilated and out of shape, sigmoid (S curved) with a dip before the stomach. If the wrap is too tight or the myotomy was not long enough or deep enough there may still be too much restriction to food passing through the LES. Over time the myotomy may grow back together or scarring may tighten causing a return or worsening of the symptoms. With or without a fundoplication acid reflux may develop and the patient may need to be on medication to suppress acid production for life. In most cases where a myotomy is not at first successful a dilatation can be used to improve it and give success. In a small portion of cases a redo of the myotomy is needed. In the rare cases where no success can be achieved after redo myotomy and dilatation an esophagectomy may be considered. By far in most cases Heller's myotomy provides years of long-term success and is generally the preferred treatment of achalasia where appropriate.