Defining the learning curve of laparoendoscopic single-site Heller myotomy.

Introduction: Initial outcomes suggest Laparo-Endoscopic Single Site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. Methods: 100 patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored utilizing a Likert scale (0=never/not bothersome to 10=always/very bothersome). Symptom resolution, additional trocar placements, and complications were compared among patient quartiles. Median data are presented. Results: Preoperative frequency/severity scores were: dysphagia=10/8, regurgitation=8/6, heartburn=2/2. Additional trocars were placed in 11 patients (11%), of whom 81% were in the first two quartiles; placement of additional trocars decreased in successive quartiles (p<0.05). Esophagotomy/gastrotomy occurred in 3 patients. Postoperative complications occurred in 9%, none specific to Heller myotomy (Table). No conversions to open operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia=2/0, regurgitation=0/0, heartburn=0/0; scores were similar and less than before myotomy across all quartiles, p<0.001(Figure). There were no apparent scars, except where an additional trocar was placed. Conclusions: LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar, without inducing reflux. Placement of additional trocars primarily occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, as proficiency is quickly attained. 25Patient Quartiles