The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.
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.
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 manometry2,3. 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 rates4,5. 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.
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
2 Ports placement and robotic docking
NOTE: A total of four 8 mm robotic ports are required for the surgery, and there is an option to add a fifth port to serve as an assistant trocar.
3 Division of phren-oesophageal ligament
4 Esophageal myotomy
5 Post-myotomy esophago-gastro-duodenoscopy
6 Post-operative care
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 their achalasia symptoms. After the myotomy, we routinely perform intraoperative esophagogastroduodenoscopy (EGD) to evaluate the gastroesophageal (GE) junction. During this examination, we ensure that the endoscope can easily pass across the cardia (Figure 1B), and we can rule out any injury using a leak test. In recent years, we have begun to utilize endoluminal functional lumen imaging probes during the operation. Our patient was chosen randomly. She is a 67-year-old with a history of psoriatic arthritis and type II Achalasia. She had been suffering from progressive dysphagia, even after a previous attempt to treat it with Botox and dilation. The procedure (Heller myotomy) was performed successfully without any complications, and no blood transfusions were needed. She was able to drink immediately after the procedure and felt obvious relief from the dysphagia. After the surgery, she was discharged home on postoperative day 1. These results following surgery allow us to be confident of a safe and complete myotomy (Table 1). The radiographic evaluation of the upper GI series done before the operation and on post-operative day 1, showing the removal of the strictures and the absence of any leaks, is depicted in Figure 6.
Figure 1: Esophagogastroduodenoscopy. (A) Preoperative esophagogastroduodenoscopy (EGD) was used to visualize the severity of achalasia and rule out other findings (GEJ malignancy and other strictures). (B) Post-myotomy esophagogastroduodenoscopy (EGD) was able to pass the endoscope across the cardia easily, and no thermal injury was found. Please click here to view a larger version of this figure.
Figure 2: Trocars placement. From the patient's left to right, the picture depicts the arrangement of 4 robotic trocars spaced approximately 8 cm apart. In addition, there is an assistant trocar positioned at the level of the right anterior axillary line. Furthermore, a Nathanson liver retractor is visible in the xiphoid region. Please click here to view a larger version of this figure.
Figure 3: Gastrohepatic ligament division. Division of the Gastrohepatic ligament, exposing the right cruse and phren-oesophageal membrane, using the bipolar energy device. Please click here to view a larger version of this figure.
Figure 4: Esophageal myotomy. The picture shows the application of traction using a robotic hook towards the anterior abdominal wall while carefully separating the muscle fibers of the esophagus until the esophageal mucosa becomes visible. Please click here to view a larger version of this figure.
Figure 5: Complete esophageal myotomy. The picture illustrates a complete esophageal myotomy spanning at least 6 cm, highlighting the preservation of the anterior Vagus nerve branch indicated by an arrow. Please click here to view a larger version of this figure.
Figure 6: Upper GI series. (A) This picture demonstrates a dilated esophagus and an EGJ stricture after ingesting barium during a GI series. (B) Following Heller myotomy, we can observe a significant relief in esophageal dilation and a significant improvement of the GEJ stricture with the passage of barium. Additionally, no evidence of a leak or free air was found. Please click here to view a larger version of this figure.
Age | 67 years |
Gender | Female |
Race | White or Caucasian |
BMI | 40 |
Intraoperative | |
Operative time, min | 160 min |
Intraoperative blood loss, mL | 20 mL |
Postoperative | |
Postoperative complications | None |
Hospital length of stay, days | 2 |
Discharge, postoperative day (POD) | POD 1 |
Table 1: Patient demographic and operation parameters.
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 procedures to perform based on their own experience and preferences. The critical point in myotomy is to obtain enough length of myotomy on both the esophageal and gastric sides. The gastric side myotomy is, at times, more challenging than the esophageal myotomy as there is now a serosal layer of the stomach wall, and the gastric sling fibers are present as well. During this dissection, it is also common to encounter large submucosal veins feeding into the left gastric venous system. If bleeding is encountered, it is recommended to use pressure and a thrombotic agent to stop the bleeding. Additionally, caution should be taken while using hook cautery to avoid injury to the esophageal mucosa and to prevent perforation9. If there are issues with exposure of the mediastinum during esophageal myotomy, the anterior portion of the diaphragmatic hiatus can be divided to increase exposure. However, if this is done, this should be closed with a permanent stitch at the completion of the case.
The advantages of robotic surgery compared to others are enhanced dexterity and greater precision due to better visualization with the three-dimensional view. Additionally, it gives the surgeon the ability to operate even in tight spaces, hence its utilization in pelvic surgery. A meta-analysis study showed a lower intra-operative perforation rate with robotic Heller myotomy compared to laparoscopic surgery (0% vs. 11%, respectively)10. The disadvantage of the robotic approach is reported higher cost11. The limitations of the laparoscopic approach include a poor range of motion and limited view and visual stability when compared to robotics.
In conclusion, in the hands of experienced surgeons, robotic surgery is safer and yields exceptional results due to its improved visualization, platform stability, and increased articulation of the instruments.
The authors have nothing to disclose.
I would like to express my sincere gratitude to Dr. DuCoin for the opportunity to study robotic foregut surgery. As a research fellow from Israel, I am grateful for the opportunity to share this robotic approach to the Heller myotomy used at our center. The authors received no funding for this work.
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 |