Journal of Gastrointestinal Surgery

, Volume 14, Issue 12, pp 1902–1909

Transcervical Heller Myotomy Using Flexible Endoscopy

  • Georg O. Spaun
  • Christy M. Dunst
  • Brittany N. Arnold
  • Danny V. Martinec
  • Maria A. Cassera
  • Lee L. Swanström
Original Article



Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach.


This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates.


Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061).


Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.


NOTES Flexible endoscopy Achalasia Heller myotomy Mediastinoscopy 


  1. 1.
    Allemann P, Perretta S, Asakuma M, Dallemagne B, Mutter D, Marescaux J. Multimedia manuscript. NOTES retroperitoneal transvaginal distal pancreatectomy. Surg Endosc 2009;23(4):882–3.CrossRefPubMedGoogle Scholar
  2. 2.
    Nassif J, Zacharopoulou C, Marescaux J, Wattiez A. Transvaginal extraperitoneal lymphadenectomy by Natural Orifices Transluminal Endoscopic Surgery (NOTES) technique in porcine model: feasibility and survival study. Gynecol Oncol 2009;112(2):405–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Perretta S, Allemann P, Dallemagne B, Marescaux J. Natural Orifice Transluminal Orifice Surgery (NOTES) for neoplasia of the chest and mediastinum. Surg Oncol 2009 Jun;18(2):177–80.CrossRefPubMedGoogle Scholar
  4. 4.
    Zacharopoulou C, Nassif J, Allemann P, Dallemagne B, Perretta S, Marescaux J, Wattiez A. Exploration of the retroperitoneum using the transvaginal natural orifice transluminal endoscopic surgery technique. J Minim Invasive Gynecol 2009;16(2):198–203.CrossRefPubMedGoogle Scholar
  5. 5.
    Fritscher-Ravens A, Patel K, Ghanbari A, Kahle E, von Herbay A, Fritscher T, Niemann H, Koehler P. Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures. Endoscopy 2007;39(10):870–5.CrossRefPubMedGoogle Scholar
  6. 6.
    Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007;39(9):761–4.CrossRefPubMedGoogle Scholar
  7. 7.
    Daniels AC. A method of biopsy useful in diagnosing certain intrathoracic diseases. Dis Chest 1949;16(3):360–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ. Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos). Gastrointest Endosc 2008;67(3):497–501.CrossRefPubMedGoogle Scholar
  9. 9.
    Willingham FF, Gee DW, Lauwers GY, Brugge WR, Rattner DW. Natural orifice transesophageal mediastinoscopy and thoracoscopy. Surg Endosc 2008;22(4):1042–7.CrossRefPubMedGoogle Scholar
  10. 10.
    Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Ogaka N, Itoh H, Kudo S. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010 Apr;42(4):265–71.CrossRefPubMedGoogle Scholar
  11. 11.
    Leschber G, Sperling D, Klemm W, Merk J. Does video-mediastinoscopy improve the results of conventional mediastinoscopy? Eur J Cardiothorac Surg 2008;33(2):289–93.CrossRefPubMedGoogle Scholar
  12. 12.
    Spaun GO, Swanstrom LL. Quo vadis NOTES. European Surgery 2008;40(5):211–9.CrossRefGoogle Scholar
  13. 13.
    Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959;36:343–52.PubMedGoogle Scholar
  14. 14.
    Kipfmuller K, Duda D, Kessler S, Melzer A, Buess G. [Endoscopic microsurgical dissection of the esophagus: a contribution to the reduction of pulmonary complications following esophageal resection? A comparative animal experiment study]. Langenbecks Arch Chir 1990;375(1):11–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Buess G, Becker HD (1990) Minimally invasive surgery in tumors of the esophagus. Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir 1990:1355–60.Google Scholar
  16. 16.
    Buess G, Becker HD, Mentges B, Teichmann R, Lenz G. [Endoscopic microsurgery dissection of the esophagus. II. Initial clinical experiences with demonstration of the surgical technic]. Chirurg 1990;61(4):308–11.PubMedGoogle Scholar
  17. 17.
    Bonavina L, Incarbone R, Bona D, Peracchia A. Esophagectomy via laparoscopy and transmediastinal endodissection. J Laparoendosc Adv Surg Tech A 2004;14(1):13–6.CrossRefPubMedGoogle Scholar
  18. 18.
    Kuzdzal J, Zielinski M, Papla B, Urbanik A, Wojciechowski W, Narski M, Szlubowski A, Hauer L. The transcervical extended mediastinal lymphadenectomy versus cervical mediastinoscopy in non-small cell lung cancer staging. Eur J Cardiothorac Surg 2007;31(1):88–94.CrossRefPubMedGoogle Scholar
  19. 19.
    Spaun GO, Zheng B, Martinec DV, Cassera MA, Dunst CM, Swanstrom LL. Bimanual coordination in natural orifice transluminal endoscopic surgery: comparing the conventional dual-channel endoscope, the R-Scope, and a novel direct-drive system. Gastrointest Endosc 2009;69(6):e39–45.CrossRefPubMedGoogle Scholar
  20. 20.
    Spaun GO, Zheng B, Swanstrom LL. A multitasking platform for natural orifice translumenal endoscopic surgery (NOTES): a benchtop comparison of a new device for flexible endoscopic surgery and a standard dual-channel endoscope. Surg Endosc 2009;23(12):2720–27.Google Scholar
  21. 21.
    Heller E. Extramukoese Cardiaplastik beim chronischen Cardiospasmus mit Dilatation des Oesophagus Mittheil. a. d, Grenzgeb. d. Med. u. Chir. 1914(Bd. xxvii):S. 141.Google Scholar
  22. 22.
    Fritscher-Ravens A, Cuming T, Jacobsen B, Seehusen F, Ghanbari A, Kahle E, von Herbay A, Koehler P, Milla P. Feasibility and safety of endoscopic full-thickness esophageal wall resection and defect closure: a prospective long-term survival animal study. Gastrointest Endosc 2009;69(7):1314–20.CrossRefPubMedGoogle Scholar
  23. 23.
    Gee DW, Willingham FF, Lauwers GY, Brugge WR, Rattner DW. Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine. Surg Endosc 2008;22(10):2117–22.CrossRefPubMedGoogle Scholar
  24. 24.
    Lee SL, Lerotic M, Vitiello V, Giannarou S, Kwok KW, Visentini-Scarzanella M, Yang GZ. From medical images to minimally invasive intervention: Computer assistance for robotic surgery. Comput Med Imaging Graph 2010 Jan;34(1):33–45.CrossRefPubMedGoogle Scholar
  25. 25.
    Bichlmeier C, Heining SM, Feuerstein M, Navab N. The virtual mirror: a new interaction paradigm for augmented reality environments. IEEE Trans Med Imaging 2009;28(9):1498–510.CrossRefPubMedGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2010

Authors and Affiliations

  • Georg O. Spaun
    • 1
  • Christy M. Dunst
    • 1
  • Brittany N. Arnold
    • 1
  • Danny V. Martinec
    • 1
  • Maria A. Cassera
    • 1
  • Lee L. Swanström
    • 1
  1. 1.Minimally Invasive Surgery ProgramLegacy HealthPortlandUSA

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