Robotic Heller Myotomy for the Treatment of Esophageal Achalasia: Technical Note

Introduction: Myotomy of the cardia is the surgical procedure of choice for esophageal achalasia. This study shows, with a video of technical note, the safety of a robotic approach to perform Heller myotomy. Description of the Video:00:34—The patient is placed in a supine, reversed Trendelenburg position with approximately 20° of inclination. A pneumoperitoneum is created by introducing a Veress needle into the left hypochondrium. A 12-mm trocar, for the robotic camera, is positioned in the left paraumbilical region. Two 8-mm robotic ports are inserted, respectively, into the right hypochondrium and the left subcostal region. A 12-mm extra port for accessory surgical instruments controlled by the assistant surgeon is placed at the supraumbilical region. 00:45—The left lobe of the liver is raised to expose the cardial region, and the base of the stomach is grabbed, pulling downward and to the right. 00:58—The upper cardial peritoneum is incised using a coagulation hook, exposing the front part of the esophagus. 01:32—The adipose tissue found at the esophageal–gastric passage will have to be removed. This contains some vessels that come from the gastric wall that will have to be coagulated using bipolar tweezers. These vessels represent the upper limit to which the myotomy can extend. 02:09—The myotomy is begun, using the coagulation hook, in the dilated area of the esophagus, above the esophageal sphincter, which appears as a whitish sclerotic area. 02:35—The longitudinal muscle fibers are hooked, lifted, and coagulated first, until the circular fibers become visible. Then, using the same technique, the circular fibers are hooked, coagulated, and then sectioned. The submucosal level appears below. 03:22—The myotomy toward the distal side is extended using the hook until it meets the oblique muscle fibers that constitute the start of the gastric muscles, and it is extended still further downward for about 1.5 cm, exposing the gastric submucosa that is generally more vascularized than that of the esophagus. 04:00—The edges of the myotomy have to be well unstuck laterally to be able to expose a third to half of the circumference of the viscera. Materials and Methods: The robotic procedure presented was performed with the aid of the Da Vinci surgical system at the Department of Digestive Surgery and Liver Unit, St. Maria Hospital, Terni, Italy. The device consists of a surgeon's console and a patient-side cart with four interactive robotic arms controlled by a telerobotic system. Results and Conclusion: The laparoscopic procedure is currently considered the gold standard for the myotomy of the cardia. In an institute that provides the Da Vinci surgical system and with experienced robotic surgeons, the robotic approach can safely be adopted. The Da Vinci System improves upon conventional laparoscopy with superior visualization, enhanced dexterity, and greater precision. In common clinical practice, robotic surgery seems feasible in the treatment of achalasia. However, the literature contains no evidence on the validity and role of this approach, and we believe that further studies need to compare different minimally invasive techniques. The authors state that none of the authors involved in the manuscript preparation has any conflicts of interest toward the manuscript itself, neither financial nor moral conflicts. Besides, none of the authors received support in the form of grants, equipment, and/or pharmaceutical items. Runtime of video: 4 mins