Name: robotic myotomy and partial fundoplication for achalasia
Uploaded: 2023-08-11T12:00:00
Description: Watch this Scientific Journal Video about Robotic Myotomy and Partial Fundoplication for Achalasia at JoVE.com

The recording of the surgical procedure and the use of its content for scientific and educational reasons were explained to the patient; he then signed a consent form, according to the Institution&#39;s human ethics committee. Written informed consent for the surgical and anesthetic procedures was also obtained.
NOTE: Patients with a confirmed diagnosis of achalasia by manometry and barium esophagram findings can be included in the protocol for robotic myotomy and partial fundoplication. A pre...

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F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., Kavitt, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACG+clinical+guidelines:+Diagnosis+and+management+of+achalasia.">ACG clinical guidelines: Diagnosis and management of achalasia.</a> American Journal of Gastroenterology. 115 (9), 1393-1411 (2020).</li><li>Triadafilopoulos, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Kagoshima+consensus+on+esophageal+achalasia.">The Kagoshima consensus on esophageal achalasia.</a> Diseases of Esophagus. 25 (4), 337-348 (2012).</li><li>Richards, W. O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Heller+myotomy+versus+Heller+myotomy+with+Dor+fundoplication+for+achalasia:+A+prospective+randomized+double-blind+clinical+trial.">Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: A prospective randomized double-blind clinical trial.</a> Annals of Surgery. 240 (3), 405-415 (2004).</li><li>Wang, X. H., Tan, Y. Y., Zhu, H. Y., Li, C. J., Liu, D. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-thickness+myotomy+is+associated+with+a+higher+rate+of+postoperative+gastroesophageal+reflux+disease.">Full-thickness myotomy is associated with a higher rate of postoperative gastroesophageal reflux disease.</a> World Journal of Gastroenterology. 22 (42), 9419-9426 (2016).</li><li>Ali, A., Pellegrini, C. 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S., Gangemi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+robotic-assisted+Heller+myotomy+for+the+treatment+of+achalasia:+A+systematic+review+with+meta-analysis.">Laparoscopic versus robotic-assisted Heller myotomy for the treatment of achalasia: A systematic review with meta-analysis.</a> International Journal of Medical Robotics and Computer Assisted Surgery. 17 (4), e2253 (2021).</li><li>Kim, S. S., Guillen-Rodriguez, J., Little, A. 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This protocol describes robotic myotomy and partial fundoplication as a treatment for achalasia. The article highlights a Heller Pinotti fundoplication, which consists of a variation of the classic Dor fundoplication. This technique, presented in the article, demonstrates the performance of three rows of sutures, instead of the classic two sutures performed in the Dor fundoplication. The optimal type of fundoplication, including total, anterior, or posterior has been extensively studied in the literature, but there is st...

Achalasia is a primary neurodegenerative esophageal motility disorder characterized by abnormal peristalsisand failure of the lower esophageal sphincter to relax1. Treatment of achalasia aims to reduce the resting pressure of the lower esophageal sphincter, thereby allowing esophageal emptying2. There are multiple options for treating achalasia, such as oral pharmacologic therapy, endoscopic pharmacologic therapy3, pneumatic dilatation4, peroral endoscopic myotomy (POEM)5, and surgical myotomy6.
Surgical myotomy, in which the muscle fibers of the lower esophageal sphincter are divided, has been described as one of the three definitive therapies for non-advanced achalasia, along with pneumatic dilatation and peroral endoscopic myotomy7,8. The addition of a fundoplication is performed as an anti-reflux procedure since the myotomy reduces the pressure of the lower esophageal sphincter, which can result in potential gastroesophageal reflux disease9,10.
Laparoscopic Heller myotomy has become the most common surgical procedure for treating achalasia due to decreased postoperative pain and reduced morbidity compared to other surgical approaches, such as thoracotomy, laparotomic, and thoracoscopic11,12. Robotic Heller myotomy has emerged as a minimally invasive alternative to laparoscopy for treating achalasia because of mechanical advantages provided by the robotic approach, such as magnified high-resolution three-dimensional visualization and minimized physiological tremor13,14,15.
This article presents a case of a 32-year-old patient with chronic dysphagia, regurgitation, and weight loss. The dysphagia was initially associated with solids, slowly progressing to liquids as well. The patient denied other clinical symptoms, such as pyrosis, epigastric pain, and postprandial fullness. An endoscopic evaluation was initially performed in order to exclude malignancy (Figure 1). The exam revealed dilatation and tortuosity of the esophagus, as well as retention of food, which was completely aspirated with the endoscope. Thickening of the mucosa was also identified, and no neoplastic lesions were detected. Narrow band imaging showed normal vascular and mucosal patterns. The gastroesophageal junction was located at the level of the diaphragmatic crus.
The investigation then proceeded with an esophageal manometry (Figure 2) and a barium esophagram (Figure 3). The manometry showed impaired gastroesophageal junction relaxation and esophagus with the absence of peristalsis. Barium esophagram findings were esophageal dilatation and delayed emptying of the barium. The diagnosis of achalasia was then established by the findings on the manometry and barium esophagram. The patient was considered eligible for robotic-assisted myotomy and partial fundoplication.
The aim of this article is to provide a step-by-step description of a robot-assisted Heller myotomy, performed at the University of S&#227;o Paulo.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Da Vinci Surgical System</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Needle driver</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar forceps</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Bipolar Fenestrated Grasper</td>
			<td>Intuitive Surgical</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Ultracision</td>
			<td>Johnson &#38;&#160; Johnson</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic myotomy and partial fundoplication for achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Representative results are shown in Table 1. The operation time was 112 min with a measured blood loss of 20 mL. The postoperative course was uncomplicated. The post-operative care was carried out in a regular hospital room. There was no need for an intensive care unit since there were no complications. A liquid diet was started after day one of the surgery - the patient did not report dysphagia. The patient was discharged in good condition on postoperative day 2, on a liquid diet. Soft food was graduall...

Watch this Scientific Journal Video about Robotic Myotomy and Partial Fundoplication for Achalasia at JoVE.com

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 article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

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.

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