Esophageal Achalasia: From Laparoscopic to Robotic Heller Myotomy and Dor Fundoplication

Massimo Arcerito, M Mazen Jamal, Martin G Perez, Harpreet Kaur, Andrew Sundahl, John T Moon, Massimo Arcerito, M Mazen Jamal, Martin G Perez, Harpreet Kaur, Andrew Sundahl, John T Moon

Abstract

Objective: Laparoscopic Heller myotomy and Dor fundoplication has become the gold standard in treating esophageal achalasia and robotic surgical platform represents its natural evolution. The objective of our study was to assess durable long-term clinical outcomes in our cohort.

Methods and procedures: Between June 1, 1999 and June 30, 2019, 111 patients underwent minimally invasive treatment for achalasia (96 laparoscopically and 15 robotically). Fifty-two were males. Mean age was 49 years (20 - 96). Esophageal manometry confirmed the diagnosis. Fifty patients underwent pH monitoring study, with pathologic reflux in 18. Preoperative esophageal dilation was performed in 76 patients and 21 patients received botulin injection. Dysphagia was universally present, and mean duration was 96 months (5 - 480).

Results: Median operative time was 144 minutes (90 - 200). One patient required conversion to open approach. Four mucosal perforations occurred in the laparoscopic group and were repaired intraoperatively. Seven patients underwent completion esophageal myotomy and added Dor fundoplication. Upper gastrointestinal series was performed before discharge. Median hospital stay was 39 hours (24 - 312). Median follow up was 157 months (6 - 240), and dysphagia was resolved in 94% of patients. Seven patients required postoperative esophageal dilation.

Conclusions: Minimally invasive Heller myotomy and Dor fundoplication are feasible. The operation is challenging, but excellent results hinge on the operative techniques and experience. The high dexterity, three-dimensional view, and the ergonomic movements of robotic surgery allow application of all the technical elements, achieving the best durable outcome for the patient. Robotic surgery is the natural evolution of minimally invasive treatment of esophageal achalasia.

Keywords: Dor fundoplication; Eckardt Score; Esophageal achalasia; Heller myotomy; Laparoscopic surgery; Robotic surgery.

© 2022 by SLS, Society of Laparoscopic & Robotic Surgeons.

Figures

Figure 1.
Figure 1.
Distribution of preoperative symptomatology in our patient population.
Figure 2.
Figure 2.
Upper gastrointestinal series showing the grade classification: Grade I (54 patients), Grade II (24 patients), Grade III (33 patients).
Figure 3.
Figure 3.
(A) Laparoscopic And (B) Robotic trocar position for Heller myotomy and Dor fundoplication: Liver retractor, A/B Working instruments ports, C Camera port, D Assistant port.
Figure 4.
Figure 4.
Division of the short gastric vessels.
Figure 5.
Figure 5.
Completed closure of the diaphragmatic crura.
Figure 6.
Figure 6.
Robotic hook dissecting the circular and oblique muscle fibers to complete the esophageal myotomy.
Figure 7.
Figure 7.
Robotic completed Heller myotomy.
Figure 8.
Figure 8.
Robotic Dor anterior fundoplication, first row of sutures between the fundus and the left side of the myotomy.
Figure 9.
Figure 9.
Completed robotic Dor anterior fundoplication.
Figure 10.
Figure 10.
Technical elements in performing either laparoscopic or robotic Heller myotomy and Dor fundoplication.
Figure 11.
Figure 11.
Clinical outcome (score 0-4, 0 as no symptoms and 4 as severe symptoms) at median follow up of 157 months (p value < 0.001 between preoperative and postoperative symptom score).

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