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Laparoscopic surgery for benign esophageal disorders.

During the 1970s and the 1980s, operations for benign esophageal disorders were often withheld or delayed in favor of less effective forms of treatment in an effort to prevent the postoperative discomfort, the long hospital stay, and the recovery time associated with open surgical procedures. For instance, pneumatic dilatation became the first line of treatment for achalasia, even though studies had shown that surgical management was clearly superior1. Since the beginning of the 1990s, thanks to the advent of minimally invasive techniques, there has been a revolution in the field of general surgery and, in particular, in the management of benign esophageal disorders. In the first part of the 1990s, it became clear that treatment of these conditions with minimally invasive procedures yielded results comparable to those of treatment with traditional operations while causing minimal postoperative discomfort, reducing the duration of hospitalization, shortening recovery time, and permitting earlier return to work. In the latter part of the 1990s and the first few years of the 21st century, minimally invasive esophageal procedures continued to evolve, thanks to better instrumentation and improved surgical expertise. In addition, as experience with these procedures accumulated and the follow-up period became longer, it became possible to analyze techniques and their results more rigorously. For instance, whereas in the first half of the 1990s a left thoracoscopic Heller myotomy was considered the procedure of choice for achalasia, the current procedure of choice is a laparoscopic Heller myotomy with partial fundoplication, which is now known to be better at relieving dysphagia and controlling postoperative reflux4-7. Similarly, whereas total fundoplication and partial fundoplication were initially considered equally effective in treating gastroesophageal reflux disease (GERD)8, long-term follow-up indicated that total fundoplication is clearly superior in controlling reflux and should be used whenever feasible9,10. In what follows, we focus on minimally invasive techniques for the treatment of achalasia and GERD.