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Page 6 of 9 Sollie et al. Mini-invasive Surg 2020;4:80 I http://dx.doi.org/10.20517/2574-1225.2020.81

Technical considerations
The technical advantages of the use of robotic operative systems are mainly enhanced visualization
and enhanced degree of movement available. In consideration of taking advantage of these benefits, it
[17]
is important to keep your visual field free of blood . This can be achieved with the proactive use of
hemostatic devices to ensure vessels are coagulated prior to disruption. Additionally, it is important to
ensure adequate mobilization of the gastroesophageal junction and the gastric fundus to effectively perform
all steps of the procedure. Additionally, the tools utilized allow for precise dissection during the myotomy.
[17]
The camera and dissectors can be used to ensure complete disruption of the LES muscle fibers .

Postoperative management
Upon completion of the procedure the patient should be extubated in the operating room. When stable,
they can be moved to the Post-Anesthesia Care Unite (PACU) and a postoperative chest radiograph
should be obtained. If the patient is in stable condition, they can be sent to the floor from the PACU with
orders for scheduled anti-emetics to prevent retching, maintenance fluids, pain management, aggressive
pulmonary toilet, and a clear liquid diet. Avoiding postoperative retching is important for maintaining
the integrity of tissues manipulated by the operation . On postoperative day 1, a water-soluble barium
[17]
esophagram is obtained to ensure no esophageal leaks are present. Orders for the clear liquid diet should be
maintained until the patient passes the postoperative swallow study. If the patient passes the swallow study,
tolerating liquid diet, voiding appropriately, and if pain is controlled, he/she can be discharged as early
as postoperative day 1. The patient should be allowed slow progression from full liquid to soft food diet
[27]
over the next 2-4 weeks . Follow-up is scheduled for 1 month. At that time, the patient can be allowed to
advance diet as tolerated and resume exercise, provided there are no complications.

REVIEW OF LITERATURE: ROBOTIC HELLER MYOTOMY
Since the first published case report of an RHM in 2001, much of the literature has sought to evaluate
the efficacy and safety of the robotic approach when compared to the already established laparoscopic
approach. These data are summarized in Table 1. Multiple studies have compared data between LHM and
RHM and revealed that there are no statistical differences in estimated blood loss (< 50 mL), operative
time, or perioperative mortality [13,17,20] . Although operative time does not show statistically significant
[13]
differences, the robotic approach has been shown to be slightly longer (122 min vs. 133 min) . Other
reports have broken down operative time relative to the number of cases performed and have shown
[17]
association with improved times as the surgeon performs more cases . This alludes to the potential for
the robotic approach to become shorter in length as surgeons gain further experience. Although similar to
LHM in many categorical results, in some studies, RHM was associated with a shorter length of hospital
stay [(1 days vs. 2 days), (2.42 days vs. 4.42 days)] [13,17] .

When considering the operative surgical goal for achalasia, RHM is effective in achieving symptomatic
relief without producing significant morbidity. Each case report indicates short-term post-operative
relief of dysphagia symptoms [22,24,25,32] . Two larger studies of greater than 50 patients reported a 92.4% and
100% rate of relief for dysphagia symptoms following operation with 80% of patients needing no further
[14]
intervention [13,27] . In comparison to LHM, Kim et al. suggests that the technical advantage of the robotic
approach allows for a longer myotomy incision, resulting in greater durability of symptomatic relief for
dysphagia. The most frequently reported long-term symptom following this procedure is reflux, which
requires medication control at a rate of 62%; however, this showed no significant difference compared to
the laparoscopic procedure .
[13]

Safety is of course the next major consideration of this operation. RHM is associated with very few
postoperative or perioperative complications. The rate of esophageal mucosal perforation is of primary
consideration throughout the literature. There are no noted mucosal perforations in any of the case reports