Name: robotic heller myotomy for advancements in surgical management of achalasia
Uploaded: 2024-02-16T14:20:00.000+00:00
Duration: 9 min 46 s
Description: Read this Scientific Article Protocol about Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia at JoVE.com

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><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.&amp;nbsp;</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&amp;deg; 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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550 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

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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.

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Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

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Duodenal stenosis is a condition that can be related to several diseases, being either intrinsic, such as neoplasm and inflammatory stenosis, or ...

Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...