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[22]
symptoms with minimal morbidity, avoiding the need for complex reoperation .

Taking all this evidence into consideration, we choose an LHM with partial fundoplication for patients with
achalasia type I and II when it is feasible. We would perform POEM when an LHM would not be feasible,
such as in patients with multiple open abdominal operations and with type III achalasia. We believe that
POEM should not be offered to children or young patients because of the risk of years of pathologic reflux.

ROBOTIC HELLER MYOTOMY FOR ACHALASIA
The same issues discussed above apply when the myotomy and partial fundoplication is performed
robotically instead of laparoscopically. We consider robotic surgery just another form of minimally invasive
surgery, and it is up to the surgeon to decide based on his/her level of comfort and experience.

[23]
In 2001, Melvin and colleagues reported the first robotic LHM in the US , and since then, the robotic
platform has been slowly embraced by many surgeons for the surgical treatment of achalasia. High‐
definition 3D vision, tremor filtration, increased degrees of freedom of surgical movements, and improved
ergonomics are well-known surgical advantages of the robot. A multicenter study comparing robotic Heller
myotomy (n = 59) with LHM (n = 62) found that intraoperative complications (i.e., esophageal perforation)
were more frequent during LHM (16% vs. 0%) while both approaches had similar success rates (92% vs.
90%) . It is of note that the perforation rate of LHM (16%) was incredibly high, questioning the experience
[24]
of the surgeons involved in the trial.

These studies have also exposed that while the results of laparoscopic and robotic myotomy are similar, the
cost of a robotic platform is much higher for both patients and the health care system. This finding will limit
the wider use of robotic myotomy until a well-conducted prospective and randomized trial will show a clear
advantage of the robotic approach.

CONCLUSION
Type I and II achalasia should be treated by an LHM with partial fundoplication, while Type III responds
better to POEM. However, POEM should not be performed in children and young patients for its high
incidence of pathologic reflux.

A robotic Heller achieves similar results to a laparoscopic procedure, but it is linked to higher costs for
patients and the health care system.

DECLARATIONS
Authors’ contributions
Authors have contributed sufficiently to the project: Patti MG, Schlottmann F, Herbella FAM

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.