I would like to express my sincere gratitude to Dr. DuCoin for the opportunity to study robotic foregut surgery. As a research fellow from Israel, I am grateful for the opportunity to share this robotic approach to the Heller myotomy used at our center. The authors received no funding for this work.

This protocol follows the guidelines of our institution&#39;s human research ethics committee. Written informed consent was obtained from the patients&#39; 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
<ol>
	<li>Place patients on a liquid diet for 3 days prior to the operation in an attempt to clear the esophagus of impacted food.</li>
	<li>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&#39;s protocol.</li>
	<li>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).
	<ol>
		<li>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&#39;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.</li>
	</ol>
	</li>
	<li>Leave the endoscope in the stomach to function as a bougie and provide counter pressure within the esophagus during the myotomy procedure.</li>
</ol>
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.
<ol>
	<li>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.</li>
	<li>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&#176; 5 mm laparoscope and optical access trocar visualization technique. Use a verses needle to inflate the abdomen when needed.</li>
	<li>Attach carbon dioxide gas insufflation and inflate the abdomen to 15 mmHg. Reinsert the 0&#176; scope and inspect the abdomen for any site of potential trocar injury. Change the laparoscope to 30&#176; to facilitate additional trocar placement.</li>
	<li>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).</li>
	<li>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.</li>
	<li>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.</li>
	<li>Dock the robot. Prepare the instruments, which include an advanced bipolar energy device, a cardia forceps, a fenestrated bipolar, and a hook cautery.</li>
</ol>
3 Division of phren-oesophageal ligament
<ol>
	<li>Divide the gastrohepatic ligament using the bipolar energy device to expose the right crus and phren-oesophageal membrane (Figure 3).</li>
	<li>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.</li>
	<li>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 .</li>
</ol>
4 Esophageal myotomy
<ol>
	<li>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.</li>
	<li>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.</li>
	<li>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.</li>
	<li>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.</li>
	<li>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.</li>
	<li>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).</li>
	<li>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)</li>
</ol>
5 Post-myotomy esophago-gastro-duodenoscopy
<ol>
	<li>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).</li>
	<li>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.</li>
	<li>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.</li>
	<li>Upon completing the procedure, remove the endoscope along with the liver retractor and ports.</li>
</ol>
6 Post-operative care
<ol>
	<li>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.</li>
</ol>

Treatment of Achalasia by Robot-Assisted Heller Myotomy

<ol>
	<li>Boeckxstaens, G. E., Zaninotto, G., Richter, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Achalasia.">Achalasia.</a> Lancet. 383, 83-93 (2014).</li><li>Goyal, R. K., Chaudhury, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pathogenesis+of+achalasia:+lessons+from+mutant+mice.">Pathogenesis of achalasia: lessons from mutant mice.</a> Gastroenterology. 39 (4), 1086-1090 (2010).</li><li>Leeuwenburgh, I., 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=Long-term+esophageal+cancer+risk+in+patients+with+primary+achalasia:+a+prospective+study.">Long-term esophageal cancer risk in patients with primary achalasia: a prospective study.</a> Am J Gastroenterol. 105 (10), 2144-2149 (2010).</li><li>Campos, G. M., 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=Endoscopic+and+surgical+treatments+for+achalasia:+a+systematic+review+and+meta-analysis.">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li><li>Lopushinsky, S. R., Urbach, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pneumatic+dilatation+and+surgical+myotomy+for+achalasia.">Pneumatic dilatation and surgical myotomy for achalasia.</a> JAMA. 296 (18), 2227-2233 (2006).</li><li>Yaghoobi, M., 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=Laparoscopic+Heller's+myotomy+versus+pneumatic+dilation+in+the+treatment+of+idiopathic+achalasia:+a+meta-analysis+of+randomized,+controlled+trials.">Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials.</a> Gastrointest Endosc. 78 (3), 468-475 (2013).</li><li>Boeckxstaens, G. E., 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=Pneumatic+dilation+versus+laparoscopic+Heller's+myotomy+for+idiopathic+achalasia.">Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.</a> N Engl J Med. 364 (19), 1807-1816 (2011).</li><li>Patti, M. G., Schlottmann, F., Herbella, F. A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Heller+myotomy+and+robotic+Heller+myotomy:+when+is+it+indicated.+Mini-invasive.">Laparoscopic Heller myotomy and robotic Heller myotomy: when is it indicated. Mini-invasive.</a> Surgery. 6, 38 (2022).</li><li>Campos, G. M., 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=Endoscopic+and+surgical+treatments+for+achalasia:+a+systematic+review+and+meta-analysis.">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li><li>Maeso, S., 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=Efficacy+of+the+Da+Vinci+surgical+system+in+abdominal+surgery+compared+with+that+of+laparoscopy:+a+systematic+review+and+meta-analysis.">Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis.</a> Ann Surg. 252 (2), 254-262 (2010).</li><li>Huffmanm, L. C., 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=Robotic+Heller+myotomy:+a+safe+operation+with+higher+postoperative+quality-of-life+indices.">Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.</a> Surgery. 142 (4), 613-618 (2007).</li></ol>

Dr. DuCoin works for Intuitive Surgical, Medtronic, and Johnson &amp; Johnson. The other authors declare no competing interests.

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...

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 manometry2,3. 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 rates4,5. 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.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>8 mm assistance port</td>
			<td>Da Vinci</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Air Seal insuflation system</td>
			<td>CONMED</td>
			<td>Ias8-120LP</td>
			<td></td>
		</tr>
		<tr>
			<td>Force bipolar grasper</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Four 8-mm robotic ports</td>
			<td>Da Vinci</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hook cautery.&#160;</td>
			<td>COVIDIEN</td>
			<td>E3773-36C</td>
			<td></td>
		</tr>
		<tr>
			<td>Nathanson liver retractor</td>
			<td>Mediflex</td>
			<td>69704-3</td>
			<td></td>
		</tr>
		<tr>
			<td>Needle driver</td>
			<td>COVIDIEN</td>
			<td>172015</td>
			<td></td>
		</tr>
		<tr>
			<td>Robotic 30&#176; endoscope</td>
			<td>Da Vinci</td>
			<td>470057</td>
			<td></td>
		</tr>
		<tr>
			<td>Robotic advanced bipolar device (Vessel Sealer)</td>
			<td>INTUITIVE SURGICAL</td>
			<td>480422</td>
			<td></td>
		</tr>
		<tr>
			<td>Two laparoscopic graspers</td>
			<td>Stortv</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic heller myotomy for advancements in surgical management of achalasia

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.

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...

Read this Scientific Article Protocol about Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia at JoVE.com

Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

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

Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the ...

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485 Views.  University of South Florida. The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia. 

Video: Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

Surgical Management of Meatal Stenosis with Meatoplasty

Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.

Meatoplasty, surgical management of meatal stenosis.

Meatal stenosis is a common urologic complication after circumcision.  Children present to their primary care physicians with complaints of deviated ...

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Therapeutic Effectiveness of a Dietary Supplement for Management of Halitosis in Dogs

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized placebo-controlled crossover clinical evaluation, we assessed&#160;the effectiveness of a dedicated dietary supplement to improve chronic halitosis in 32 dogs of different breeds and ages. This protocol describes how to evalute the presence of oral volatile suphur compunds, e.g. methyl mercaptan, hydrogen sulfide and dimethyl sulfide, by means of a portable gas chromatograph device coupled with a syringe, which was used to collect the breath, and a dedicated software, which allows the operator to monitor each compound concentration during each measurement, in a relatively short time (8 min).
A significant modification of halitosis parameters was observed after 30 days since the beginning of treatment (p &#60;0.05), while a long-lasting effect was still observed even 20 days after the suspension of the treatment. Portable gas chromatograph, which is also widely used in clinical practice, can be therefore used to confirm&#160;and control halitosis in humans and animals. Even though human and animal species present some differences,&#160;this innovative and alternative therapy for halitosis management might be extended to human clinical practice as an adjuvant dietary approach.

We describe a simple approach for diagnosis of halitosis in dogs as well as a dietary approach for its management. This protocol may be extended to the management of halitosis in humans in the near future.

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

Real-Time Telemetric Impedance Measurements During Cochlear Implantation

Performing Repeated Intraoperative Impedance Telemetry Measurements during Cochlear Implantation

Impedance measurements are routinely performed during cochlear implantation (CI) after finalized electrode insertion. They may allow conclusions on the electrode's and implant's function. In the postoperative setting, the analysis of impedance changes enables the identification of scarring or inflammation processes around the electrode. Recent studies report associations between impedance telemetry and the site of stimulation. Consequently, repeated impedance measurements during cochlear implant electrode insertion may enable objective feedback on whether the electrode is positioned inside the perilymph or outside the inner ear. With the presented novel method, impedances can be measured in real-time during cochlear implantation. This protocol systematically explains how to perform repeated impedance recordings during CI surgery. These repeated measurements are challenging since they depend on multiple intraoperative methodological factors starting with the draping of the patient. Thus, for successful recordings, a standardized procedure is mandatory. In this article, we comprehensively illustrate the system setup and procedure of performing intraoperative measurements during CI surgery.

Author Spotlight: Advancements in Impedance Monitoring for Cochlear Implant Surgery

Here we present a protocol to conduct repeated impedance telemetry measurements during cochlear implantation (CI). They may allow conclusions on the electrode's and implant's function. Repeated impedance measurements enable objective feedback on whether the electrode is positioned inside the perilymph or outside the inner ear.

Impedance measurements are routinely performed during cochlear implantation (CI) after finalized electrode insertion. They may allow conclusions on the ...

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.

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 ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Procedure for Targeted Muscle Reinnervation for Treating Postamputation Pain

Targeted Muscle Reinnervation: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the functionality of prosthetic limbs. Notably, novel surgical interventions have had an additional positive outcome, as individuals with amputations have reported neuropathic pain relief after undergoing such procedures. Subsequently, surgical techniques have gained increased prominence in the treatment of postamputation pain, including one such surgical advancement - targeted muscle reinnervation (TMR). TMR involves a surgical approach that reroutes severed nerves as a type of nerve transfer to &#34;target&#34; motor nerves and their accompanying motor end plates within nearby muscles. This technique originally aimed to create new myoelectric sites for amplified electromyography (EMG) signals to enhance prosthetic intuitive control. Subsequent work showed that TMR also could prevent the formation of painful neuromas as well as reduce postamputation neuropathic pain (e.g., Residual and Phantom Limb Pain). Indeed, multiple studies have demonstrated TMR&#39;s effectiveness in mitigating postamputation pain as well as improving prosthetic functional outcomes. However, technical variations in the procedure have been identified as it is adopted by clinics worldwide. The purpose of this article is to provide a detailed step-by-step description of the TMR procedure, serving as the foundation for an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394), including nine clinics in seven countries. In this trial, TMR and two other surgical techniques for managing postamputation pain will be evaluated.

Author Spotlight: Advancements and Challenges in Surgical Treatments for Postamputation Pain

The protocol outlines the surgical procedure&#160;for the treatment of postamputation pain using Targeted Muscle Reinnervation (TMR). TMR will be compared with two other surgical techniques, specifically Regenerative Peripheral Nerve Interface (RPNI) and neuroma excision, followed by immediate burying within muscle under the context of an international, randomized controlled trial.

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the ...

RPNI Surgery for Treating Postamputation Pain

Regenerative Peripheral Nerve Interface: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain

Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past decade. Primarily developed to increase the functionality of prosthetic limbs, these surgical procedures have also been found to reduce postamputation neuropathic pain. Today, some of these procedures are performed more frequently for the management and prevention of postamputation pain than for prosthetic fitting, indicating a significant need for effective solutions to postamputation pain. One notable emerging procedure in this context is the Regenerative Peripheral Nerve Interface (RPNI). RPNI surgery involves an operative approach that entails splitting the nerve end longitudinally into its main fascicles and implanting these fascicles within&#160;free denervated and devascularized muscle grafts. The RPNI procedure takes a proactive stance in addressing freshly cut nerve endings, facilitating painful neuroma prevention and treatment by enabling the&#160;nerve to regenerate and innervate an end organ, i.e., the free muscle graft. Retrospective studies have shown RPNI&#39;s effectiveness in alleviating postamputation pain and preventing the formation of painful neuromas. The increasing frequency of utilization of this approach has also given rise to variations in the technique. This article aims to provide a step-by-step description of the RPNI procedure, which will serve as the standardized procedure employed in an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394). In this trial, RPNI is compared to two other surgical procedures for postamputation pain management, specifically, Targeted Muscle Reinnervation (TMR) and neuroma excision coupled with intra-muscular transposition and burying.

Author Spotlight: Regenerative Peripheral Nerve Interface (RPNI) Surgery in Postamputation Pain Management

Here, we describe the surgical procedure to perform Regenerative Peripheral Nerve Interface (RPNI) surgery for treating postamputation neuropathic pain in the context of an international, randomized controlled trial (RCT) (ClinicalTrials.gov, NCT05009394). The RCT compares RPNI with two other surgical techniques, namely, Targeted Muscle Reinnervation (TMR) and neuroma excision combined with intra-muscular transposition.

Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past ...