Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Summary

The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.

Abstract

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.

Introduction

Achalasia is an esophageal motility disorder. The most common cause of achalasia is idiopathic, characterized by impairment of the circular and longitudinal muscular layers of the esophagus due to the destruction of the myenteric nerves in the lower esophageal sphincter (LES)¹. This leads to the inability of the LES to relax. Achalasia is also associated with an increased risk of esophageal squamous cell carcinoma. The gold standard for diagnosing achalasia is manometry^2,3. However, endoscopy should be performed to rule out other causes of narrowing, such as gastro esophageal junction (GEJ) malignancy and other strictures.

The treatment of achalasia is divided into surgical and non-surgical options. Non-surgical treatments include the use of drugs such as calcium channel blockers and nitrates, as well as endoscopic treatments like dilation or botulinum toxin injection. Non-surgical treatments have high recurrence rates^4,5. Surgical treatment, specifically laparoscopic or robotic myotomy, originally described as the heller myotomy, can be performed with or without an anti-reflux procedure. Surgical treatment provides the best long-term treatment and relieves achalasia symptoms by dissection of the muscles in the affected part of the esophagus around the LES⁶.

The decision to perform a fundoplication following Heller myotomy remains controversial. In theory, anti-reflux procedures, such as the Dor or Toupet procedures, reduce the risk of gastroesophageal reflux disease (GERD) following myotomy. Peroral endoscopic myotomy (POEM) has been developed as an option in the treatment of achalasia. Through a proximal submucosal tunnel, the muscular layer of the affected esophagus is divided distally to the level of LES and cardia⁷. We perform the Heller myotomy using a robotic approach. The robotic platform offers enhanced high-definition visualization of distal esophageal and hiatal anatomy, advanced range of motion, and decreased complication rates when compared to the laparoscopic approach⁸. Despite all the advantages of the robotic approach, the method and approach to surgical treatment of achalasia decision ultimately lies with the surgeon and is dependent on the available resources, level of comfort, and experience with the available techniques. The goal of this protocol is to serve as a guide and a valuable resource for training new foregut surgeons, as well as residents, making the steps of the surgery clear and understandable.

Protocol

This protocol follows the guidelines of our institution's human research ethics committee. Written informed consent was obtained from the patients' cases reviewed for the protocol. Inclusion criteria – patients of all ages who were diagnosed with achalasia based on clinical manifestations, manometric criteria, and radiographic studies. Exclusion criteria – achalasia symptoms due to gastroesophageal malignancy. 1. Preoperative preparation Place patients on a…

Representative Results

At our academic tertiary care center, both intraoperative and postoperative complications of Heller myotomy are extremely rare. Between 2020 and August 2023, post-Heller myotomy perforation rate was 0% utilizing the robotic approach. During this period, we performed 105 robotic Heller myotomy. Blood loss is generally less than 20 mL, and we did not transfuse blood for any patient; hospital stay length rarely exceeds postoperative day 1, and patients are able to drink immediately after surgery, experiencing relief of thei…

Discussion

Laparoscopic and robotic Heller myotomy is now the procedure of choice with or without fundoplication⁶. The primary contentious issues revolve around the necessity of fundoplication after Heller myotomy, as well as the type of fundoplication (Toupet, Dor, Nissen) to minimize GERD. Peroral endoscopic myotomy (POEM) is another option for achalasia treatment; however, this option lacks a fundoplication procedure⁸. Therefore, surgeons should make decisions regarding which proce…

Materials

8 mm assistance port	Da Vinci
Air Seal insuflation system	CONMED	Ias8-120LP
Force bipolar grasper
Forceps
Four 8-mm robotic ports	Da Vinci
Hook cautery.	COVIDIEN	E3773-36C
Nathanson liver retractor	Mediflex	69704-3
Needle driver	COVIDIEN	172015
Robotic 30° endoscope	Da Vinci	470057
Robotic advanced bipolar device (Vessel Sealer)	INTUITIVE SURGICAL	480422
Two laparoscopic graspers	Stortv