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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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 ...

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