胸腔镜下食管肌层切开术（图文演示）

10. End/myotomy

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By pushing the diaphragm downwards, the circular fibers of the gastroesophageal junction can be meticulously identified. Metzenbaum scissors are carefully passed under the fibers, gently pulling them away from the mucosa. The fibers are divided over 1 to 2 cm at a time using scissors or a hook.
It is preferable to ignore the mild bleeding caused by this division, rather than risk cauterization that might damage the fine mucosa at this level. A temporary tamponade and irrigation are enough to clear the operative field.

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The 2 edges of the myotomy are spread apart with 2 graspers.
The mucosa is irrigated with serum and dried.
The scope is positioned near the mucosa to check for any muscular fibers that might have been left intact; if found, they are divided with an electrocautery hook.

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A nasogastric tube is carefully inserted under visual guidance. With a grasper, the surgeon manipulates the tip of the nasogastric tube to reach the superior edge of the myotomy.
Mucosal damage is checked by instilling either serum or methylene blue onto the mucosa and injecting air through the tube.

11. End/procedure
The nasogastric tube is removed. A 24 French thoracic drain is placed in the posterior mediastinum. Care must be taken to keep its tip away from the exposed mucosa.
The lung is reinflated and the trocar sites are closed with the usual techniques.

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Care
A postoperative water-soluble contrast swallow is done on POD1.
Once the integrity of the myotomy has been demonstrated, the drain may be removed on POD1 and food intake resumed.
The patient may leave hospital on POD3.

Complications
The complications are not specific to this intervention. They can occur after any thoracoscopy.

Prolonged air leak results from a small parenchymal opening when the lower lobe of the lung is grasped. The drain must be left in place until the air leak disappears.

If pleural effusion occurs, it is generally minimal, limited to the filling of the pleural cul-de-sac. No treatment is required other than prescribed respiratory exercises.

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