Laparoscopic cardiomyotomy: Historical overview and current operative approach

Laparoscopic cardiomyotomy (LCM), or surgical disruption of the muscular fibers of the lower esophageal sphincter (LES), is the definitive operative management of achalasia. The workup of the patient includes a detailed history and physical, endoscopy, esophagogram, and high-resolution manometry. Confounding etiologies of pseudoachalasia are identified during this initial evaluation. Endoscopic interventions for achalasia, such as pneumatic dilation and botulinum toxin injection, may precede surgery; patients are often referred for operative cardiomyotomy after progressive treatment failure or, in younger populations, as a primary measure. When assessed together, high-resolution manometry and the patient's response to prior interventions offer prognostic value and guide further steps toward or away from surgery. While the treatment of achalasia has evolved dramatically throughout history, the general principles have remained the same: whether using a rigid whale bone or robotic-assisted hook cautery, therapy is aimed at permanently disrupting the thickened muscle fibers of the LES. Prior to the advent of minimally invasive techniques, formal cardiomyotomy was performed via open thoracotomy or laparotomy to complete both an anterior and posterior myotomy. Currently, a laparoscopic approach with anterior myotomy and partial fundoplication is the accepted standard of care. Robotic-assisted cardiomyotomy is a recent and valuable addition to possible operative approaches, providing improved visualization of the hiatus. We describe our operative approach and institutional experiences, and finally, discuss directions for the future of this procedure.