LAPAROSCOPIC TREATMENT OF ESOPHAGEAL ACALASIA Professor Enrico Croce, MD and et al ( M.Azzola, R. Russo, M. Golia and S. Olmi) , from the Scuola Speciale Ospedaliera A.C.O.I. Di Chirurgia Laparoscopica e Mini-Invasiva, Milano, Italy are presenting a case of laparoscopic treatment of esophageal acalasia. " We believe that acalasia must be treated with a long extramucosal miotomy of the esophagus and of the first two centimeters of the gastric wall to be sure of total annulment of HPZ. For this reason in order to avoid the risk of GER we associated a 180 degree anterior hemifundoplicaton according to Dor." The operation consists in the creation of a hemi-fundoplication of about 180° that covers the anterior surface of the oesophagus. In addition to the reinforcement action of the LES, the cardiac incisure is reconstructed and a segment of oesophagus is retained in the abdomen. Yet the anti-reflux effect tends to deteriorate fast in time, so this type of plasty is used mainly in association with other operations and not as a primary operation for correcting GERD. The execution of a fundoplication according to Dor is illustrated in association with an extra-mucosal myotomy of the oesophagus for achalasia. The top of the gastric fundus is seized by the forceps of the assistant and taken cranially adjacent to the oesophagus. A laparoscopic stitch in non-absorbable thread, for extra-corporeal knotting, takes the part of the anterior wall of the stomach next to the gastro-oesophageal angle and fixes it to the edge of the left oesophageal muscle wall of the tract most distal to the myotomy. The apex of the gastric fundus is grasped by the forceps in the left hand of the operator. Another stitch fixes it to the most cranial tract of the muscle wall of the left edge of the myotomy. During this manoeuvre, the assistant can draw the oesophagus into the abdomen by taking the gastric wall at the lesser curvature with the forceps. The most cranial stitch of the first series of sutures has been placed and the needle has already been withdrawn outside to make an extra-corporeal knot. The position of the most cranial stitch is important, because it determines the length of the intra-abdominal tract of the oesophagus. Once the suture of the stomach to the left edge of the oesophagus has been completed, the operator takes the left edge of the anterior gastric wall with the left forceps and takes it to the right edge of the oesophagus very close to the crus of the diaphragm. The most cranial stitch of the right edge of the fundoplication is placed. This, too, must be positioned so that it helps to retain the chosen segment of oesophagus in the abdomen. The first right stitch has been placed. When withdrawing the thread, it is important to use the forceps in the loop as a pulley in between so as to avoid tearing the muscle wall of the oesophagus while the thread is running through. Lastly, the right inferior edge of the hemi-fundoplication is sutured. The operation has been completed. The gastric valve completely covers the abdominal part of the extra-mucosal myotomy. A cross-section of the hemi-fundoplication. One notes that the valve consists of a slip of the anterior wall of the stomach that folds upon itself. Laparoscopy.com would like to thank Prof. Enrico Croce for his CD-ROM contribution BIT SURGERY - Multimedia Surgical - Surgery of the Functional Diseases of Oesophagus. For further information regarding how to get the complete series of CD-ROM and Video about Multimedia Surgical, please contac STEFANO OLMI, MD or write to Prof. Enrico Croce. Scuola Speciale Ospedaliera A.C.O.I. Di Chirurgia Laparoscopica e Mini-Invasiva. 1st. Divisione di Chirurgia, Corso di Porta Nuova, 23 - 20121 - Milano, Italy.