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Sollie et al. Mini-invasive Surg 2020;4:80 I http://dx.doi.org/10.20517/2574-1225.2020.81 Page 7 of 9

Table 1. Summary of data from retrospective studies
Type of Operative time Risk of
Ref. procedure No. of patients (min) LOS (days) perforation (%) Cost ($)
Shaligram et al. [10] 2012 RHM 149 - 2.42 ± 2.69 - 9,415 ± 5,515 a
LHM 2116 - 2.70 ± 3.87 - 7,441 ± 7,897 a
Villamere et al. [30] 2015 RHM 314 - 2.26 ± 2.05 a - 9,258 ± 4,278 a
LHM 3135 - 2.78 ± 3.55 a - 7,425 ± 5,693 a
[13]
Perry et al. 2014 RHM 56 133 ± 29 1 a 0.0 a -
LHM 19 121 ± 22 2 a 16.0 a -
Kim et al. [14] 2019 RHM 37 158 2.02 2.7 -
LHM 35 157 2.17 11.4 -
[15]
Ali et al. 2019 RHM 44 183.5 a 1 0.0 a -
LHM 40 157 a 1 15.0 a -
POEM 87 169 1 1.1 -
Huffmanm et al. [18] 2007 RHM 24 355 ± 23 ǂ 2.8 0.0 -
LHM 37 287 ± 9 ǂ 2.6 8.1 -
[21]
Khashab et al. 2017 RHM 52 263 b 2.3 0.0 17,782 b
POEM 52 106 b 1.9 7.7 14,481 b
Pallabazzer et al. [27] 2020 RHM 66 161.4 ± 40.2 - - -
[31]
Saurabh et al. 2014 RHM 12 150 1.5 - -
a
Meta-analyses, case reports, and case series not included in this chart. Indicates that there was statistically significant difference (P
b
< 0.05) in data when RHM was compared to LHM; Indicates that there was statistically significant difference (P < 0.05) in data when
ǂ
RHM was compared to POEM; operative time for this study was measured as time of anesthesia induction to extubation. LOS: length of
stay; RHM: robotic Heller myotomy; LHM: laparoscopic Heller myotomy; POEM: per oral endoscopic myotomy
and only 1 perforation noted in the retrospective reviews [14,15,21,22,24,25,27,32] . In a review of the progression
of the role of myotomy, Allaix and Patti highlight two separate studies that show rates of mucosal
[33]
perforation in LHM being 16% and 8%, while the RHM groups had a 0% perforation rate in both studies.
A meta-analysis further confirmed the safety of RHM in view of the significantly fewer mucosal injuries,
[20]
and stated that it is safer than the laparoscopic approach . As mucosal perforation leads to greater
perioperative morbidity, the evidence reported in these studies should be strongly considered when
thinking of the safety of the patient in choosing the operative approach.

The technical advantages to this procedure are believed to be associated with the enhanced 3-D
visualization and the increased degree of movement of the surgical instruments with robotic systems [13,31,34] .
The enhanced visualization and increased precision of control are believed to contribute to having fewer
mucosal perforations and to the ability to make longer incisions for the myotomy [13,14,31] . In consideration
of disadvantages of robotic operations, multiple studies cite cost. The cost analyses performed show
statistically significant higher cost when comparing RHM to LHM, with one study citing as much as a 21%
increase when comparing robotic to laparoscopic surgeries [17,19,21,30] . One multicenter study demonstrated
[10]
that LHM was significantly less expensive than RHM ($7,441 vs. $9,415, P = 0.0028) ; another found a
[30]
similar difference ($7,425 for LHM vs. $9,258 for RHM, P < 0.05) . Further efforts should be made to
analyze cost associated with robotic procedures and discover ways to mitigate charges to help overcome
this barrier.

Most of the research on RHM is retrospective in nature and with small cohorts, posing some limitations
regarding prospective application of the data. However, enough evidence has been derived from these
studies to provide grounds for further investigation. Future randomized control studies are needed for
confirmation of suspected outcomes.

CONCLUSION
RHM with Dor (or Toupet) fundoplication is an extremely safe and effective procedure for relieving
symptoms of esophageal achalasia. Use of this approach is associated with almost no complications related