Robotic Heller myotomy and Dor fundoplication: Twelve steps

摘要

Central MessageThe Robotic approach to Heller myotomy and Dor fundoplication provides excellent visualization of the layers of the esophageal wall, which helps in decreasing the rate of mucosal injury. The Robotic approach to Heller myotomy and Dor fundoplication provides excellent visualization of the layers of the esophageal wall, which helps in decreasing the rate of mucosal injury. Achalasia is an esophageal motor disorder that is characterized by failure of the lower esophageal sphincter (LES) to relax and loss of peristalsis in the esophageal body.1Werner Y.B. Hakanson B. Martinek J. Repici A. von Rahden B.H.A. Bredenoord A.J. et al.Endoscopic or surgical myotomy in patients with idiopathic achalasia.N Engl J Med. 2019; 381: 2219-2229Crossref PubMed Scopus (253) Google Scholar Treatment options focus on releasing the elevated pressure of the LES and include direct botulinum toxin injection, pneumatic dilation, per-oral endoscopic myotomy (POEM), and Heller myotomy. Botulinum toxin's effect is temporary, requiring repeated injections with progressively diminished efficacy over time. The effectiveness of pneumatic dilation has been shown in previous studies. When compared with Heller myotomy, pneumatic dilation was associated with a greater risk of esophageal perforation that required emergency surgery.2Boeckxstaens G.E. Annese V. des Varannes S.B. Chaussade S. Costantini M. Cuttitta A. et al.Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia.N Engl J Med. 2011; 364: 1807-1816Crossref PubMed Scopus (646) Google Scholar POEM is the most recently developed treatment option for achalasia. Its effectiveness in relieving dysphagia has been proven, but the lack of accompanying fundoplication predisposes to increased esophageal reflux.1Werner Y.B. Hakanson B. Martinek J. Repici A. von Rahden B.H.A. Bredenoord A.J. et al.Endoscopic or surgical myotomy in patients with idiopathic achalasia.N Engl J Med. 2019; 381: 2219-2229Crossref PubMed Scopus (253) Google Scholar Adding a partial fundoplication, whether anterior or posterior, to Heller myotomy decreases the risk of esophageal reflux from approximately 50% without a fundoplication to less than 10% with a partial fundoplication.3Richards W.O. Torquati A. Holzman M.D. Khaitan L. Byrne D. Lutfi R. et al.Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial.Ann Surg. 2004; 240: 405Crossref PubMed Scopus (448) Google Scholar, 4Kummerow Broman K. Phillips S.E. Faqih A. Kaiser J. Pierce R.A. Poulose B.K. et al.Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: long-term symptomatic follow-up of a prospective randomized controlled trial.Surg Endosc. 2018; 32: 1668-1674Crossref PubMed Scopus (33) Google Scholar, 5Brown J. Egger M. Kehdy F.J. Heller myotomy: to wrap or not to wrap?.Am Surg. 2018; 84: 1022-1026Crossref PubMed Scopus (3) Google Scholar Until recently, the gold standard treatment of achalasia has been laparoscopic Heller myotomy with partial fundoplication. However, the robotic approach continues to expand its use for foregut operations. Extending the esophageal mediastinal dissection further up into the chest is facilitated using the robot. It also provides good visualization of the esophageal layers, which translates into an easier and safer myotomy. This robotic approach is described in 12 steps. The technique of robotic Heller myotomy and Dor fundoplication is described in a series of 12 distinct steps, each with an accompanying video. The described approach uses the da Vinci Xi system (Intuitive Surgical). A list of full instrumentation is provided. No institutional review board/ethical review board approval was required. Informed consent was obtained from the patient for the video recording and its use in education and research. Robotic instruments 1.8-mm 30° camera (0° optional)2.Four 8-mm robotic ports3.Small grasping retractor (liver retra