Robot-assisted Heller myotomy for achalasia

Since its first description in 19911, laparoscopic Heller myotomy has been associated with better short-term outcomes and shorter recovery time, compared to open operation. Given this high success rate2, it was soon generally accepted as the procedure of choice for achalasia over the nonsurgical treatment options, such as medical treatment with calcium channel blockers or nitroglycerin, endoscopic injection of botulinum toxin into the distal esophagus and balloon dilation. In fact, the introduction of laparoscopic Heller myotomy for achalasia was associated with a two-fold increase in use of surgery in the United States during a 12-year period from 1993 to 20053. Despite the well-known benefits of laparoscopy, some studies reported an esophageal perforation rate up to 15%4. Although these perforations are usually repaired during the operation without any sequelae, this kind of complication expose the patient to a long hospital stay and the risk for a potentially fatal esophageal leak. Robotic technology has recently been introduced into laparoscopic clinical practice with the aim of improving surgical performance. Since 2000, when the Food and Drug Administration approved the robotic surgery for applications in general laparoscopic surgery, several authors showed excellent results with robotic Heller esophageal myotomy5-8. Despite the lack of randomized trial, the robotic-assisted Heller myotomy in patients with achalasia appears to be associated with a lower risk of perforation, compared with standard laparoscopic operation9. The same authors suggest a possible benefit in Quality of life. The use of a robotic-assisted laparoscopic procedure seems to be particularly useful for those operations where a higher degree of skills is required (i.e. esophageal Correspondence to: Mario Morino, MD, General Surgery and Center for Minimal Invasive Surgery, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy (e-mail: [email protected]) Mario Morino, Federico Famiglietti, Claudio Giaccone, Fabrizio Rebecchi