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Page 2 of 9 Sollie et al. Mini-invasive Surg 2020;4:80 I http://dx.doi.org/10.20517/2574-1225.2020.81
[1-6]
age, whereas other studies describe a bimodal incidence by age with peaks around ages 30 and 60 years .
The etiology of achalasia remains unclear, although it is purported to be multifactorial. The most common
form of achalasia is idiopathic.

Although rare, achalasia is likely the best described primary esophageal motility disorder with clear
[2,3]
clinical, manometric, endoscopic and radiologic findings . Commonly reported symptoms associated
with achalasia include progressive dysphagia with liquids and then solids, heartburn, regurgitation,
odynophagia, weight loss, nocturnal cough and chest pain. Manometry is the gold standard for diagnosis
of achalasia into 3 subtypes with different manometric patterns: Type I (classic achalasia of aperistalsis
and failure of the LES to relax), Type II (with esophageal compression) and Type III (spastic achalasia)
[3,7]
as defined by the Chicago classification . Endoscopy will demonstrate food particles in the absence of a
mucosal stricture and a narrowed gastroesophageal junction, the latter of which is well learned as the “bird’s
[3,7]
beak” appearance on barium esophagram .
The treatment of achalasia is not curative. It is a progressive disease that leads patients to seek symptom
palliation, which can be accomplished by reducing the resting and swallow-induced pressures of the
LES [1,3,7-10] . That is, therapy is aimed at relieving the functional obstruction. This can be done with medical,
endoscopic and surgical therapies. Medical therapies include drugs such as nitrates and calcium channel
[3,7]
blockers that act to relax smooth muscle . Endoscopic sphincteric injection of Botox has also been
performed with limited and variable success rates, whereas graded pneumatic dilation has more robust
results [7,11] . In comparison, minimally invasive Heller myotomy is currently the gold standard surgical
approach for achalasia as it has the best long-term outcome. Although per-oral endoscopic myotomy
(POEM) and robotic Heller myotomy (RHM) are increasingly being used, laparoscopic Heller myotomy
(LHM) is the longest practiced surgical approach with safe and effective outcomes [8,9,12-15] .

With recent advancements in technology, RHM has become an alternative option for the treatment of
[16]
achalasia. It was first described in 2001 in a case report by Melvin et al. . At this point, outcomes are
somewhat controversial for RHM compared to LHM; however, many studies report that it is equivalent to
LHM in terms of achieving the desired result of symptomatic relief but with fewer complications related to
mucosal perforation [9,13,14,17-20] . Cost remains one of the largest barriers to overcome in robotic operations;
however, cost reduction strategies can be further explored with increased utilization [10,17,19,21] .

ROBOTIC HELLER MYOTOMY AND PARTIAL FUNDOPLICATION
Perioperative preparation, positioning and port placement
The patient is placed supine on the operating room table with both arms tucked at the sides. Foot boards
should be secured at the end of the table to prevent the patient from sliding down the table. A dose of
perioperative antibiotics (first-generation cephalosporin) is administered within 1 h of incision. After
induction with general anesthesia, a single-lumen endotracheal tube is used for intubation. Upper
endoscopy is then performed and the scope left in the stomach with the light turned off. The patient’s
abdomen is then prepped and draped in a sterile manner.

The Da Vinci Xi surgical system (Intuitive Surgical Inc., Sunnyvale, CA, USA) is used for our operation.
A total of 5 or 6 ports can be used for this procedure. Afaneh et al. describe a 5-port set up transversely
[17]
across the abdominal midline. The first port is placed in the midline roughly 15 cm below the xiphoid
process. Three additional 8-mm robotic ports and a 5-mm retractor port are then placed . A case report
[17]
[22]
in the pediatric population also describes a 4-port method . We elect to use 6 ports during our procedure.
Port location is shown in Figure 1. The first port is placed in the right lower quadrant using the Optiview
technique with a 12-mm port. Intraperitoneal insufflation with carbon dioxide is set to a target pressure
of 15 mmHg. This 12-mm port is used by the bedside assistant for passage of suture, suctioning, and