Robotic assisted Heller myotomy: indications, techniques and outcomes

Abstract

Achalasia is defined as an esophageal motility disorder that is characterized by two components: impaired peristalsis and the inability of the lower esophageal sphincter to relax. While the etiology is unknown, many studies suggest that the pathophysiology lies in the destruction of the ganglion cells of the mesenteric plexus located in the muscularis propria layer of the esophagus. Treatment of achalasia begins with various endoscopic interventions. However, these endoscopic interventions can require multiple interventions and are not free of morbidity and mortality. The definitive treatment for achalasia associated with superior long-term symptom relief is a Heller myotomy. The Heller myotomy was first performed by Dr. Ernest Heller on April 14, 1,913 where he used an anterior and posterior incision to obliterate the dysfunctional LES in a patient with achalasia. Inevitably, the Heller myotomy procedure has evolved most notably in the 90s where the first minimally invasive esophagomyotomies were reported both with thoracoscopic and laparoscopic approaches. The first cases of robotic assisted Heller myotomy (RAHM) were reported in 2001. Since then, a number of studies have reported its equivalence in outcomes to the laparoscopic, endoscopic, and open approaches as well as areas in which the robot may prove to be superior.