Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Podsumowanie

The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.

Streszczenie

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.

Wprowadzenie

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 manometry^2,3. 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 rates^4,5. 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.

Protokół

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

1. Place patients on a liquid diet for 3 days prior to the operation in an attempt to clear the esophagus of impacted food.
2. Place the patient in the supine position and administer general endotracheal anesthesia (GETA) via a rapid sequence induction (RSI) while holding cricothyroid pressure to reduce the risk of aspiration during intubation. To provide Cricothyroid pressure, apply manual pressure on the cricoid cartilage to occlude the esophagus.
   NOTE: The RSI technique is conducted via the administration of appropriate anesthetic agents and neuromuscular blocking agents per the anesthesiologist's protocol.
3. After successful endotracheal intubation, perform an esophagogastroduodenoscopy (EGD) to assess the level of achalasia severity and dislodge any solid food stuck in the esophagus, if needed (Figure 1A).
   1. 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 to facilitate insertion, and then gently insert the endoscope through the patient's mouth into the esophagus under direct visualization.
      NOTE: Usually, there is a pop of pressure as the endoscope is passed through the gastroesophageal junction with pressure.
4. Leave the endoscope in the stomach to function as a bougie and provide counter pressure within the esophagus during the myotomy procedure.

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.

1. Following skin sterilization and preparation using an antiseptic solution, perform a small skin incision of approximately 1 cm using a blade at each planned trocar insertion site in order to insert the trocar into the abdominal cavity.
2. Place the first port site at 15 cm below the xiphoid process, 1-2 cm to the left of the abdominal mid-line, using a 0° 5 mm laparoscope and optical access trocar visualization technique. Use a verses needle to inflate the abdomen when needed.
3. Attach carbon dioxide gas insufflation and inflate the abdomen to 15 mmHg. Reinsert the 0° scope and inspect the abdomen for any site of potential trocar injury. Change the laparoscope to 30° to facilitate additional trocar placement.
4. Under direct vision, place three 8 mm robotic trocars in a transverse line at the level of the first port with 4-8 cm between each port (try to leave 8 cm between each port to reduce collisions within the robotic arms). Locations of robotic ports (from patient left to right) are approximately at the left anterior axillary line, left mid-clavicular line, and right mid-clavicular line (Figure 2).
5. Place an additional assistant trocar in the right flank at the level of the right anterior axillary line, just above the level of the umbilicus.
6. Place a Nathanson liver retractor in the xiphoid region to elevate the left lateral lobe of the liver and expose the hiatus. This will expose the entire left upper quadrant, ensuring excellent exposure for the operation.
7. Dock the robot. Prepare the instruments, which include an advanced bipolar energy device, a cardia forceps, a fenestrated bipolar, and a hook cautery.

3 Division of phren-oesophageal ligament

1. Divide the gastrohepatic ligament using the bipolar energy device to expose the right crus and phren-oesophageal membrane (Figure 3).
2. Identify the phreno-esophageal membrane and divide it using the bipolar energy device toexpose the longitudinal muscle fibers of the esophagus. Extend and dissect the avascular plane between the esophagus and mediastinum from the right crus to the left crus after dividing the phren-oesophageal ligament.This dissection should expose the anterior surface of the esophagus.
3. Identify and preserve the anterior vagus nerve. Elevate and dissect the anterior vagus nerve off of the esophagus to facilitate the preservation of the nerve and to ensure a complete myotomy beneath the nerve .

4 Esophageal myotomy

1. Dissect the gastroesophageal fat pad on the anterior surface using an electrocautery hook from the level of the stomach to expose the GEJ; start the dissection at the distal fat pad.
2. Extend the dissection proximally to the left crus using an electrocautery hook, and then medially dissect towards the right crus with care to preserve and protect the anterior vagus, which often courses through the medial aspect of the fat pad.
3. Before performing the myotomy, completely expose the distal portion of the esophagus and the anterior portion of the proximal stomach to allow for the appropriate length of myotomy.
   NOTE: The goal for myotomy length should be a minimum of 6 cm in the distal esophagus and 2 cm in the proximal stomach.
4. Begin the myotomy just proximal to the GEJ on the side of the esophagus, approximately 1 cm proximal. This approach will help the surgeon avoid the sling fibers of the stomach, which can occasionallycause confusion during dissection.
5. Exchange the robotic advanced bipolar instrument for the robotic hook. With great care, start the myotomy 1 cm proximal to the GE junction with a brief application of 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.
6. After the mucosa is visualized, repeat the traction motion of the hook (with minimal use of cautery) to tear the esophageal muscular fibers proximally onto the esophagus. Continue dissection until either the view becomes obstructed or the dissection has reached a point where repairing an injury would be challenging. Ensure that it is at least 6 cm in length (Figure 4 and Figure 5).
7. After completing the proximal myotomy, continue the dissection down onto the side of the stomach.
   NOTE: A technical consideration during myotomy is to prioritize the tearing of muscle fibers rather than using cautery. This helps to minimize the risk of thermal injury. However, if cautery is used, it is recommended to pull the circular fibers away from the esophagus before applying cautery. (Figure 4)

5 Post-myotomy esophago-gastro-duodenoscopy

1. Perform an EGD to evaluate the GEJ. Ensure that the endoscope easily passes across the cardia and use visual inspection to ensure that there is no thermal injury (Figure 1B).
2. Perform a leak test by inflating the esophagus and stomach with air while submerging them in water. Evaluate for the presence of gas bubbles, which could indicate a leak.
3. After completing the myotomy,proceed with a Dor to Toupet fundoplication if indicated.
   NOTE: If a Toupet fundoplication is performed, posterior dissection of the hiatus is necessary. However, if a Dor fundoplication is to be performed, there is no need to disturb the posterior attachments of the esophagus.
4. Upon completing the procedure, remove the endoscope along with the liver retractor and ports.

6 Post-operative care

1. In the postoperative period, administer a multi-modal pain regimen with anti-inflammatory and opioid medications. Start patients with a clear liquid diet on the day of surgery. On postoperative day 1, perform a radiographic evaluation with an upper GI series to evaluate for leaks (Figure 6B). Most patients are discharged on postoperative day 1 with instructions to follow a full liquid diet until post-operative evaluation in the surgery clinic within 2 weeks.

Wyniki

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 thei...

Dyskusje

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 proce...

Materiały

Name	Company	Catalog Number	Comments
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