Cardia myotomy

Patients with achalasia who have failed medical treatment or have other esophageal lesions. Cardiac myometomy precautions: 1. The esophagus and cardia should be fully exposed and easy to operate to ensure that the myometrial incision is long enough and cut thoroughly. 2. The vagus nerve must be clearly identified before the incision of the muscle layer, such as the string-like bundle at the left front of the esophagus is the vagus nerve, otherwise it is easy to be confused with the muscle layer fibers. If the nerve is injured, the esophagus and stomach will dilate. 3. The incision of the esophageal muscle layer must be long enough, which is the key to the success of the operation. The incision must reach the plane where the enlarged esophagus begins to shrink; however, the lower end should not be too long, extending to the upper part of the stomach, generally not more than 2 cm, so as not to cause gastric reflux. According to the requirements of surgery, the incision of the esophagus muscle layer is not less than 5-8cm; however, the esophagus is poorly exposed through the abdominal route, and the abdominal segment is only 3cm long. Therefore, it is often necessary to cut the vagus nerve to pull down the esophagus. The vagus nerve can only cut off the left branch and keep the right branch, which can reduce the effect on the function of the digestive tract. After the vagus nerve has been cut off, the esophagus can be easily pulled down by about 5cm, thereby ensuring the length of the muscular incision. In order to ensure that the pylorus is unobstructed and promote gastric emptying, it is best to add pyloroplasty, that is, make a longitudinal incision in the anterior wall of the pylorus, and make sutures across the entire layer. If the vagus nerve is not damaged, pyloroplasty may not be performed. 4. The incision of the muscle layer of the esophagus should be thorough, and any circular muscle fibers must be cut to make the mucosa between the incisions bulge completely outward to achieve satisfactory results. This is also one of the keys to successful surgery. In order to accurately determine whether the muscle fibers of the esophagus and cardia are completely cut off, a purse suture can be made under the longitudinal incision at the bottom of the stomach, and a traction line is sutured on the opposite side of the opening of the purse suture. Cut the stomach wall [Figure 3-1]. The surgeon can use the left index finger to reach into the esophageal cavity from this small incision. Under the guidance of the fingers, use a knife to cut the muscle layer of the esophagus and cardia one by one. Anyone who can feel the restriction of the circular muscles must be completely cut off. Fully swell the mucosa [Figure 3-2]. Finally, pull out the index finger, tighten the pouch and ligate it, and then add a few needles to the suture of the muscular layer. This method can completely cut the muscle layer of the esophagus and cardia to ensure the effect of surgery. It is especially suitable for the inexperienced surgeon. 5. Cut the muscle layer carefully and slowly to avoid cutting the mucosa. If accidentally ruptured, it is often seen that the air bubbles or the bulging mucosa collapse, and can be repaired with a thin needle suture immediately. If suture repair is not satisfactory or the rupture is too large to be sutured, gastroesophageal side-to-side anastomosis can be changed.