Robotic Heller Myotomy

Abstract

Achalasia is a rare esophageal dysmotility disorder of unknown etiology that affects approximately 1 in 100,000 people. It is characterized by haphazard contractility or absent peristalsis of the esophagus and uncoordinated relaxation of a hypertensive lower esophageal sphincter (LES) mechanism. The combination of esophageal dysmotility and uncoordinated LES relaxation produces the debilitating symptoms of achalasia, i.e., symptoms of esophageal outlet obstruction (e.g., dysphagia with liquids and solids and regurgitation, aspiration), as well as other symptoms associated with esophageal spasm, like chest pain. Treatment for achalasia has evolved considerably over the past 30 years. From thoracotomies and celiotomies to endoscopic techniques (e.g., pneumatic balloon dilations and botulinum toxin injections and, most recently, POEM) to minimally invasive surgical techniques (e.g., laparoscopic myotomy, to laparo-endoscopic single-site [LESS] myotomy, to robotic myotomy). Today, Heller myotomy is considered the “gold standard” therapy for achalasia, alleviating symptoms by defunctionalizing the lower esophageal sphincter mechanism. We have undertaken Heller myotomy on over 700 patients. Herein, we outline our surgical technique for robotic Heller myotomy, which is based upon this experience.