Local epinephrine facilitates laparoscopic Heller myotomy

Incomplete myotomy and mucosal perforation are the most common technical complications of laparoscopic esophageal myotomy. The muscle layers of the lower esophagus are infiltrated with a 1:100,000 epinephrine solution using a thin needle. Gentle pressure is applied with a peanut sponge to diminish the edema produced by the injections. The longitudinal fibers are separated with a dissector and the semicircular fibers are lifted from the submucosa with a dissector or a hook. The muscle transection is done simply by tearing the fibers or cutting them with scissors. No coagulation is required. Infiltration and topical application of epinephrine solution allowed the performance of 22 laparoscopic esophageal myotomies with excellent visualization, complete muscle division, and without any esophageal or gastric perforation. Injection and topical application of epinephrine solution to the area of the esophagus and stomach which will be subjected to myotomy greatly facilitates the procedure and helps to avoid complications.