Robotic Myotomy and Partial Fundoplication for Achalasia

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This video demonstrates the steps of a robotic myotomy and partial fundoplication in a 30-year-old patient with megaesophagus. Place a Nathanson liver retractor in subxiphoid position, in order to elevate the left lobe of the liver.

Start the operation by dividing the short gastric vessels, starting from the middle of the great curvature of the stomach all the way to the angle of His. Perform full mobilization of the gastric fundus, using an ultrasonic harmonic scalpel to free it from retroperitoneum, while an automatic grasper retracts the stomach. Divide the gastrohepatic ligament below the hepatic branch of the vagus, and progressively dissect in order to identify and expose both diaphragmatic crura.

Be aware to preserve the hepatic branch of the vagus during this dissection. Place a tape around the esophagus, allowing gentle traction. Proceed with the isolation of the esophagus by separating it from the left and right crura by blunt dissection.

During the dissection, be aware to identify and preserve the posterior and anterior vagal trunks and both pleurae. The anterior vagal trunk is adhered or embedded in esophageal wall, and the posterior trunk lies on the layer of adipose tissue posterior to the esophagus. Mobilize the esophagus circumferentially, creating a longer intraabdominal esophagus.

Remove the fat pad by holding the adipose tissue that lies above the phrenoesophageal ligament, and separate it circumferentially from the esophagus wall with a harmonic scalpel in order to expose and better visualize the gastroesophageal junction. Before performing the myotomy, mark the esophageal wall with the bipolar forceps in the anterior midline of the esophagus, with an extension approximately six centimeter above the gastroesophageal junction. Grasp the borders of the myotomy, and disrupt the muscular layer while moving the borders away from each other until exposure of the submucosal layer.

Proceed the myotomy with the harmonic scalpel by interposing the inactive jaw of the scalpel between the submucosal and muscular layer and activating the trigger in order to cut and cauterize. During this dissection, make sure to separate the muscle's edges of the myotomy laterally, thus avoiding them to fuse when healing. Use a sterile measuring stripe to ensure the length of the myotomy is six centimeters above the gastroesophageal junction and three centimeters below it.

Continue the demarcation and myotomy below the gastroesophageal junction laterally into the stomach as the muscle fibers change direction from circular to oblique. Adequate extension of myotomy is crucial to achieve good postoperative results and avoid recurrence of dysphagia. Perform the repair of the hiatus with figure of eight stitches, with 2.0 cotton sutures.

Be aware not to tighten the hiatus, which may lead to postoperative dysphagia. Proceed with the Heller-Pinotti fundoplication. Mobilize the gastric fundus, and bring it around the back of the esophagus in order to perform the suturing of the gastric fundus to the posterior wall of the distal esophagus.

Perform interrupted stitches with 2-0 cotton sutures, and attach the seromuscular layer of the stomach to the muscular layer of the esophagus. The extension of the suture should correspond to that of the myotomy. Usually, two or three stitches are enough.

The first stitch of that row should also incorporate the hiatus. Although this maneuver does not prevent the migration of the valve, it restrains its rotation. Resect a muscular strip over the gastroesophageal junction when needed.

Next, perform the second row of sutures from the gastric fundus to the left edge of the myotomy. As with the first row, the initial stitch should also be attached to the hiatus. Perform the third and last row of sutures from the gastric fundus to the right edge of the myotomy.

By the end of these steps, the exposed submucosa of the esophagus should be covered by gastric serosa. The operation time was 112 minutes, with a measured blood loss of 20 milliliters. Postoperative course was uncomplicated.

A liquid diet was started after day one of surgery, and the patient did not report dysphagia. The patient was discharged in good condition on postoperative day two, on a liquid diet. Soft food was gradually introduced after day five.

The patient did not develop any complications during the follow-up. A barium esophagram was performed 30 days after surgery. The exam showed an adequate emptying of the barium, with no contrast retention and a normal aspect of the fundoplication.

While laparoscopic Heller myotomy is currently considered the gold standard treatment for achalasia, robotic-assisted myotomy can also be a successful alternative in the hands of experienced surgeons and should be considered as a feasible treatment option, in the field of minimally invasive treatments, for achalasia.