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Gharagozloo et al. Mini-invasive Surg 2020;4:22 I http://dx.doi.org/10.20517/2574-1225.2019.61 Page 7 of 9

[18]
patients undergoing laparoscopic myotomy and fundoplication for achalasia, Finley et al. reported a
median operative time of 1.9 h, one mucosal perforation that was amenable to laparoscopic repair, 96%
patient satisfaction for relief of dysphagia, and a 9% rate of new postoperative gastroesophageal reflux.

A generous anterior myotomy including onto the gastric cardia has been advocated to prevent incomplete
myotomy presenting as residual achalasia. To prevent postoperative reflux, a fundoplication should be
performed as well. The fundoplication has also been demonstrated to prevent the formation of a mucosal
diverticulum following myotomy, a condition which may have added to the problem of chronic dysphagia
[18]
in these patients with compromised esophageal dysmotility .

On the other hand, the surgeons who have advocated myotomy without an antireflux procedure, most
[4]
notably Ellis et al. , have emphasized that, in their experience, fundoplication recreates the resistance
to esophageal emptying and that, depending on the degree of resistance, fundoplication can lead to
progressive esophageal dilation and ultimately the same sequalae as with untreated achalasia. Furthermore,
based on performing a lateral esophageal myotomy, these authors have asserted that, in their experience, if
the esophageal myotomy is carried onto the cardia by up to 2 cm, an antireflux procedure is not required.

The present understanding of the gastroesophageal antireflux barrier has served to explain the different
observations and the discrepancy in the experience of the proponents versus the opponents of an added
antireflux procedure to the modified Heller myotomy. Based on this understanding, by nature of not
disrupting the three-dimensional relationship at the esophageal hiatus and performing a very careful
and limited myotomy, the surgeons who did not add an antireflux procedure were able to preserve the
antireflux barrier and accomplish the goal of the myotomy without the need for an antireflux procedure.
On the other hand, surgeons who opened the esophageal hiatus and performed an extensive dissection of
the gastroesophageal junction, thus disrupting the normal antireflux barrier, needed to add an antireflux
procedure to the myotomy in order to prevent postoperative reflux. It is important to note that, to visualize
an adequate length of esophagus, a transabdominal approach invariably needs to disrupt the anatomy at
the gastroesophageal junction and the antireflux barrier. Consequently, all transabdominal approaches to
esophageal myotomy have required the addition of an antireflux procedure.

This is a retrospective review of patients who underwent a robotic laparoscopic esophageal myotomy
without fundoplication. RLHM was performed without complications or mortality. There was significant
decrease in the pressure and length of the lower esophageal high-pressure zone on manometry. The
manometry data correlated with the significant decrease in the subjective dysphagia score. In addition, the
objective Eckhardt scores decreased significantly and remained unchanged at 12 months following RLHM,
signifying the long-term efficacy of the procedure. The rate of pathologic reflux following RLHM was very
low. This finding is further evidence that RLHM preserves the gastroesophageal valve and does not require
a fundoplication.

Long-term results of the laparoscopic anterior esophageal myotomy with an antireflux are excellent.
Theoretically, by virtue of three-dimensional high definition magnification, and precise instrument
maneuverability, the robotic laparoscopic approach may be associated with better outcomes for a procedure
that requires exceptional surgical precision and visualization. In addition, the use of the surgical robot in
performing a lateral esophageal myotomy may obviate the need for a fundoplication.

Given the excellent relief of dysphagia, and very low incidence of post myotomy gastroesophageal reflux,
RLHM should be considered in patients with achalasia.