Heller Myotomy

Achalasia, a disease of unknown etiology, results in failure of lower esophageal sphincter (LES) relaxation and aperistalsis. The incidence is about 1 in 100,000 in North America. Options for medical management include medication, botulinum toxin injection, and balloon dilatation. None of nonsurgical treatments have been as successful as surgical myotomy. Many years after Heller performed the first surgical myotomy, the minimally invasive surgical techniques became the gold standard of the surgical treatment for the achala-

sia. However, the surgeons are still hampered by their inability to have flexible instruments and high-definition video imaging. The robotic system is ideally suited for advanced esophageal surgery, and we have applied this technology in our surgical approach to achalasia. The myotomy is extended a minimum of 6 cm proxi-mally and 1-2 cm distally onto the gastric fundus. Failure to achieve adequate proximal dissection of the esophagus with a subsequent short myotomy is the most common reason for failure. Therefore, the dissection of the esophagus should extend well into the thorax in order to complete the myotomy. The laparo-scopic approach in this small area is often difficult and frequently the visual field is obscured by the instrumentation. The articulating wrists of the robot enable the surgeon to operate in the narrow field around the thoracic esophagus without this limitation. Perforation of the esophageal mucosa, seen in 5-10% of laparoscopic cases independent of the surgeon's experience, is the most feared complication when performing a Heller myotomy. The three-dimensional view with x12 magnification and the natural tremor of the surgeon's hand eliminated through electronic filtering of the robotic system allow each individual muscular fiber to be visualized and divided ensuring a proper myotomy, diminishing dramatically the incidence of perforation (Fig. 9.3). Following the myotomy and crural closure, we complete a Dor fundoplication. In the last 4 years, our group performed 50 robotically assisted myotomy for achalasia at our institution. In our series, we have not experienced a single perforation, even though many of our patients were treated with Botox preoper-atively; a similar number of cases have been compiled by Dr. Melvin at Ohio State University, with similar results. The average length of hospital stay is 1.5 days (range: 0.8-4), with no conversions and a 100% success rate. We strongly believe that the robotic-assisted approach will be the gold standard for Heller myotomy in the near future.

Fig. 9.3 Robotic myotomy of circular esophageal fibers
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