Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

The goal of protocol is really to standardize an approach to a very complex operation, provide a valuable resource for other surgeons and surgical learners to have a really step-by-step method to perform the operation in a safe and efficient manner that leads to the highest quality outcome. The treatment of achalasia, there's multiple means, but the most robust and durable is what's called a Heller myotomy, and there's two different ways you can perform that. One is laparoscopically, which is kind of the older way and the newer, more modern, is with robotic surgery.

With this protocol, we really dive deep into the robotic treatment of achalasia with the Heller myotomy, showing its advantages over a laparoscopic approach. It's complex, but the protocol simplifies it and makes it more durable and shows great value. So, we have a large research institute and we're continuously going to study achalasia and its treatment options.

With this new protocol, we will continue to study it, really looking for the durability and the long-lasting nature of the myotomy and the various ways to approach it. We'll look for other options, but yes, we're gonna continue to study this, hopefully collaborate with other research institutes to get more patients, better outcomes, and dive deeper into the data. So, the advantage of the protocol with the robotic platform, one, it's its standardization.

So now, we finally have really well described, easy-to-follow steps to the operation. And then with the robotic platform, with the dexterity of the instruments, the articulation, the ability to move and really find spaces, it's really like microscopic surgery. Compounding that with a three-dimensional view, it's far superior to laparoscopy, and we've showed improved outcomes within the operating room, decreased risk of complications.

Now we just need to study that and see if it's a better definitive treatment for achalasia as well. We know it's better in the OR, we think it's gonna be better long term as well. Yeah, so we will need to continuously question and study achalasia.

Right now, there is no cure for the disease. All of the treatment options really are just treating the symptoms, doing that myotomy, releasing the muscle, making it easier for people to eat and swallow. But really we need to study the durability.

We want to dive deep into the questions and answer what is the most durable, what process or treatment is gonna lead to the longest lasting outcomes so we can treat you once and have that last the rest of your life. Our belief is this protocol with a robotic platform is just that, but we'll continuously study this. To begin, place the patients on a liquid diet to clear the esophagus of impacted food.

On the day of the procedure, place the patient in a supine position. Then provide cricothyroid pressure by applying manual pressure on the cricoid cartilage to occlude the esophagus. Administer general endotracheal anesthesia via a rapid sequence induction while applying cricothyroid pressure to reduce the risk of aspiration during intubation.

After successful endotracheal intubation, perform an esophagogastroduodenoscopy to assess the level of achalasia severity. Ensure the endoscope is clean and properly connected to the video monitor and light source. Confirm that the water and air channels are functioning correctly.

Lubricate the distal end of the endoscope, and then gently insert it through the patient's mouth into the esophagus under direct visualization. Leave the endoscope in the stomach to function as a bougie and provide counter pressure within the esophagus during the myotomy procedure. For ports placement, first, sterilize the skin and apply an antiseptic solution.

Next, use a blade to perform a one-centimeter skin incision at each trocar insertion site. Using a zero-degree five-millimeter laparoscope and optical access trocar visualization technique, place the first port site 15 centimeters below the xiphoid process, one to two centimeters to the left of the abdominal midline. Attach carbon dioxide gas insufflation and inflate the abdomen to 15 millimeters of mercury.

Reinsert the zero degree scope and inspect the abdomen for any site of potential trocar injury. Then change the laparoscope to 30 degrees. Next, under direct vision, place eight millimeter robotic trocars in a transverse line at the level of the first port, approximately at the left anterior auxiliary line, left midclavicular line, and right midclavicular line.

Place an additional assistant trocar in the right flank at the level of the right anterior auxiliary line, just above the level of the umbilicus. Next, place a Nathanson liver retractor in the xiphoid region to elevate the left lateral lobe of the liver and expose the hiatus. Dock the robot.

Prepare the instruments, including an advanced bipolar energy device, a cardio forceps, a fenestrated bipolar, and a hook cautery. Divide the gastrohepatic ligament using the bipolar energy device to expose the right crus and phrenoesophageal membrane. Then divide the phrenoesophageal membrane to expose the longitudinal muscle fibers of the esophagus.

After dividing the phrenoesophageal ligament, extend and dissect the vascular plane between the esophagus and mediastinum from the right crus to the left crus, exposing the anterior surface of the esophagus. Identify the anterior vagus nerve, elevating and preserving it to ensure a complete myotomy beneath the nerve. Then use an electrocautery hook to dissect the gastroesophageal fat pad on the anterior surface from the level of the stomach.

After exposing the gastroesophageal junction, start the dissection at the distal fat pad. Extend the dissection proximally to the left crus using an electrocautery hook. And then medially, dissect towards the right crus, protecting the anterior vagus.

Completely expose the distal portion of the esophagus and the anterior portion of the proximal stomach before performing the myotomy. Begin the myotomy proximal to the gastroesophageal junction on the side of the esophagus. Exchange the robotic advanced bipolar instrument with the robotic hook.

Briefly apply cautery energy with the robotic hook. Using traction of the robotic hook towards the anterior abdominal wall, carefully divide the esophageal muscle fibers until the esophageal mucosa is visualized. Then repeat the traction motion of the hook to tear the esophageal muscular fibers proximally onto the esophagus.

Continue dissection for at least six centimeters until the view becomes obstructed or up to the point when further repair is challenging. After completing the proximal myotomy, continue the dissection onto the side of the stomach. Post myotomy, perform an esophagogastroduodenoscopy to evaluate the gastroesophageal junction.

Ensure that the endoscope easily passes across the cardia and visually inspect for any thermal injury. Perform a leak test by inflating the esophagus and stomach with air and submerging them in water. Evaluate for the presence of gas bubbles indicating a leak.

Upon completing the procedure, remove the endoscope, liver retractor and ports. Using this protocol, Heller myotomy was performed on a 67-year-old patient suffering from type II achalasia. The procedure was conducted without complications and no blood transfusions were needed.

The patient showed immediate postoperative drinking ability and dysphagia relief, leading to discharge on the first postoperative day. Radiographic evaluations of the upper GI series before and after surgery confirmed the effective removal of strictures without leaks.