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BACKGROUND: The surgical treatment of achalasia remains controversial. Controversies include open vs. videoendoscopic approach, laparoscopic vs. thoracoscopic approach, and the need for an antireflux procedure. Laparoscopic Heller myotomy is hampered by the need for an additional antireflux procedure. Thoracoscopic Heller myotomy does not require an antireflux procedure, but is associated with greater rates of residual achalasia. Robotics by virtue of 3-D visualization and greater maneuverability may facilitate thoracoscopic Heller myotomy.
METHODS: From 12/05 to 11/11, 26 patients underwent robot-assisted thoracoscopic esophageal myotomy for achalasia without an antireflux procedure. Diagnosis of achalasia was confirmed by radiography, endoscopy, and manometry. Patients underwent intraoperative EGD. Robot-assisted myotomy was accomplished through 4 ports in the left chest. Myotomy was extended approximately 1 cm onto the proximal stomach. Success of the myotomy was determined by intraoperative EGD, postoperative contrast radiography, subjective symptom questionnaire, and Viscik grading.
RESULTS: There were 8 men and 18 women. 14/26 (%) patients had undergone botulinum toxin injection. Mean operative time was 237 +/- 36 minutes. There were no mucosal injuries or conversion to a thoracotomy. Median hospitalization was 3 days. All patients reported improvement in dysphagia. Symptom relief was graded as: Viscik I = 23 patients, Viscik II = 3 patients. 10/26 patients reported symptoms which mimicked reflux but were not associated with objective reflux. Objectively proven gastroesophageal reflux was seen in 1 patient.
CONCLUSION: The surgical robot facilitates thoracoscopic Heller myotomy. Although greater experience is needed, the preliminary results of this study suggest that robot-assisted thoracoscopic Heller myotomy without an antireflux procedure may represent an excellent alternative to laparoscopic myotomy with an antireflux procedure.