Heller Myotomy

CPT 43330
Approach Laparoscopic
Add-on / Variant CPTs
  • 43279 — Laparoscopic esophagomyotomy
  • 43280 — With fundoplication
Preoperative Diagnosis:

Achalasia / esophageal dysmotility disorder

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic Heller myotomy with Dor (anterior) partial fundoplication

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male/female] with manometry-confirmed achalasia [Type I/II/III] presenting for laparoscopic Heller myotomy. Preoperative workup included [esophagram showing bird-beak deformity / high-resolution manometry / EGD]. [Prior pneumatic dilation/botox injections had/had not been performed.] The risks, benefits, and alternatives including POEM were discussed with the patient, and informed consent was obtained.

Findings:

The lower esophageal sphincter was [hypertrophied / with thickened muscle fibers]. The esophagus was [dilated / sigmoid-shaped]. [A mucosal injury was/was not encountered during myotomy.] [An intraoperative EGD confirmed complete myotomy with loss of the lower esophageal high-pressure zone and absence of mucosal injury.] [Additional findings or none].

Description of Procedure:

The patient was brought to the operating room and placed in reverse Trendelenburg position. General endotracheal anesthesia was induced. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.

The abdomen was prepped and draped in sterile fashion. Pneumoperitoneum was established to 15 mmHg. Five trocars were placed in a configuration similar to antireflux surgery: a 12-mm umbilical port, two 5-mm working ports, a 5-mm liver retractor, and a 5-mm left lateral port.

The liver was retracted superiorly. The pars flaccida of the gastrohepatic ligament was divided. The phrenoesophageal membrane was incised anteriorly, exposing the esophagogastric junction. [Limited] anterior mobilization of the distal esophagus was performed, preserving the posterior vagal trunk. The anterior fat pad overlying the GEJ was resected to expose the esophageal muscular wall.

The myotomy was begun on the esophagus [4-6 cm above the GEJ] using [hook electrocautery / Harmonic scalpel]. The longitudinal and circular muscle fibers of the esophagus were divided under [direct vision / intraoperative endoscopic guidance] down through the GEJ and extending [1.5-2 cm onto the gastric wall]. Complete division of all muscle fibers was confirmed by visualization of the submucosal bulge across the entire myotomy length.

Intraoperative upper endoscopy was performed to confirm complete myotomy with loss of the high-pressure zone, absence of mucosal perforations, and adequate submucosal exposure across the myotomy length. [No perforation was identified.] The endoscope was removed.

A Dor anterior partial fundoplication was performed to protect the exposed mucosa and provide partial anti-reflux protection. The fundus was folded anteriorly over the myotomy and secured to the right and left edges of the myotomy with [interrupted 2-0 Ethibond] sutures, and to the right crus superiorly, creating a 180-degree anterior partial wrap.

The trocars were removed under visualization. Hemostasis confirmed. 12-mm fascial defects were closed with [0-Vicryl]. Skin was closed with [4-0 Monocryl]. Sterile dressings were applied.

Complications:

None

Specimens:

Anterior fat pad sent to pathology

Estimated Blood Loss:

Minimal (less than 20 mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Achalasia, Type ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic Heller myotomy with Dor anterior fundoplication
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with manometry-confirmed achalasia Type ***. *** prior dilation/botox. POEM discussed as alternative. Informed consent obtained.

FINDINGS: LES hypertrophied. Esophagus ***. Intraoperative EGD confirmed complete myotomy, no mucosal injury.

DESCRIPTION OF PROCEDURE:
Reverse Trendelenburg. Five trocars. General anesthesia. Surgical timeout per protocol.

Pars flaccida divided. Anterior phrenoesophageal membrane incised. Anterior fat pad excised. Myotomy begun *** cm above GEJ extending 1.5 cm onto stomach. All muscle fibers divided; submucosal bulge confirmed. Intraoperative EGD confirmed completeness and no mucosal perforation.

Dor anterior fundoplication: fundus secured over myotomy with interrupted 2-0 Ethibond to myotomy edges and right crus.

Fascia closed. Skin with 4-0 Monocryl.

ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Anterior fat pad to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Intraoperative Mucosal Perforation

A small mucosal perforation was identified during the myotomy at the [level of the GEJ / distal esophagus]. The defect measured approximately [___] mm. The perforation was repaired primarily with [interrupted 3-0 Vicryl] sutures. Intraoperative endoscopy confirmed an intact repair without air leak. The Dor anterior fundoplication was placed over the repair site to provide additional reinforcement. An oral contrast swallow was planned for postoperative day 1 to confirm integrity.

With Toupet Posterior Partial Fundoplication

A Toupet posterior 270-degree partial fundoplication was performed instead of a Dor anterior wrap. A posterior window was created and the fundus was passed behind the esophagus. The wrap was secured to each side of the myotomy and to each crus.

Charting Tips
  • Document the myotomy length explicitly — standard is 4-6 cm on the esophagus and 1.5-2 cm onto the gastric wall. Inadequate gastric extension is the most common cause of persistent dysphagia and treatment failure.
  • Document intraoperative endoscopy findings — confirm that endoscopy was performed, that the high-pressure zone was abolished, and that no mucosal perforation was seen. This is the standard of care for Heller myotomy and its absence in the note is a documentation gap.
  • If a mucosal perforation occurs and is repaired, document it fully with the repair technique — it is not a failure of care but must be documented with the endoscopic confirmation of repair and the postoperative swallow study plan.
Billing Tips
  • Bill 43279 for laparoscopic Heller myotomy (21.55 wRVU, 90-day global). This is the standard code for laparoscopic esophagomyotomy for achalasia.
  • Bill 43330 for open abdominal Heller myotomy (21.64 wRVU) or 43331 for open transthoracic approach (22.48 wRVU) if conversion or primary open approach is used.
  • When a fundoplication (Dor or Toupet) is performed at the same setting, it is typically bundled into the myotomy code — it is not separately billable as 43280 (Nissen fundoplication). Document the anti-reflux procedure as part of the myotomy operative note.
  • 90-day global period: postoperative dysphagia evaluation, esophagram, and office follow-up are bundled. Intraoperative esophagoscopy (43200) performed to confirm mucosal integrity may be separately billable — document it as a distinct service.
  • Preoperative manometry and esophagram results must be documented in the medical record to support the achalasia diagnosis and justify the procedure for payer review.