The operation, indicated for cases of diffuse oesophageal spasm, consists in dividing the muscle wall of the oesophagus via left thoracoscopic access from the diaphragmatic hiatus to the arch of the aorta. One sees, in the foreground, horizontal and downwards, the distal thoracic aorta. The retractor raises the lung and pushes it upwards and cranially, highlighting the inferior pulmonary ligament.

The pulmonary ligament is clearly visible and under tension. Incision of the pleura at its base begins, along the edge of the aorta.

The pleural incision has proceeded cranially as far as the aortic arch.

Often, the oesophagus is not easy to recognise, since it is surrounded by adipose tissue. With a pledget, it is sought in the supra-oesophageal tract, where it is less hidden by the gradual crossover with the aorta. Downwards and to the left, one recognises the diaphragmatic fibres of the hiatus.

Using scissors or a dissector, the longitudinal muscle fibres constituting the external layer are retracted, avoiding any damage to the main trunk of the left vagus nerve.

The hook now loads the transverse muscle fibres of the internal layer, moving them away from the underlying mucosa and dividing them via coagulation.

While two forceps grasp and hold the oesophageal muscle walls, already divided, the hook, now turned caudally, completes internal muscle division as far as the diaphragm.

Once myotomy has been completed, one notes the characteristic protruding aspect of the oesophageal mucosa along the tract where the muscle wall has been freed.

LAPAROSCOPY.COM would like to thank Prof. A. Cuschier, 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 contact STEFANO OLMI, MD or write to GDS Elettronica 22063 Cantu - Como (Italy) Tel +39+31 712419.