Robotic heller myotomy

Indications

Achalasia, although rare, is one of the most common motility disorders of the esophagus. It is characterized by aperistalsis of the esophagus and failure of receptive relaxation of the lower esophageal sphincter (LES). Both features are required for diagnosis. Patient symptoms can include dysphagia, heartburn, sensation of impacted food bolus after meals, and regurgitation. ^, Diagnosis is usually delayed due to these nonspecific symptoms, which are commonly mistaken for gastroesophageal reflux. Diagnosis of the disease requires manometric studies to confirm the absence of peristalsis with a food bolus as well as a high resting pressure of the LES and failure of receptive relaxation. ^, A barium esophagram demonstrating a “bird’s beak”—a dilated esophagus with tapering of the LES—may also aid in preoperative planning.

Multiple treatment options exist, including botulinum toxin injection of the LES and endoscopic pneumatic balloon dilation, which may be appropriate for patients who are poor surgical candidates. ^, However, surgical myotomy is reported to have fewer relapses of symptoms. Although surgical division of the LES performed endoscopically (known as peroral esophageal myotomy [POEM]) has been described, Heller myotomy continues to be the gold standard treatment modality. This is mostly due to the ability to perform esophagomyotomy under direct visualization as well as to perform a concomitant antireflux procedure. The addition of a fundoplication has been proven to help reduce postoperative gastroesophageal reflux after myotomy and associated conditions like esophagitis and Barrett’s esophagus.

With the increasing use of robotic surgical systems in foregut surgery, robot-assisted Heller myotomy has been performed more frequently. ^, Robot-assisted Heller myotomy has shown similar efficacy as laparoscopic Heller myotomy, with the added benefit of a decreased frequency of esophageal perforation compared to the standard laparoscopic technique.

Patient preparation

Complete medical history is taken with specific attention to the chief complaint. All patients undergo preoperative diagnostic imaging, including high-resolution esophageal manometry and a barium esophagogram. Preoperative endoscopy is not performed routinely.