TUCSON, ARIZ. — Heller myotomy performed with robotic telesurgery for the treatment of achalasia appears to cause fewer esophageal perforations and an equivalent functional outcome, compared with the traditional laparoscopic technique, W. Scott Melvin, M.D., said at the annual meeting of the Central Surgical Association.
Laparoscopic Heller myotomy for achalasia requires advanced laparoscopic skills, especially in performing what may be the toughest part of the operation—dividing the muscle fibers of the esophagus, where perforation can occur, noted Dr. Melvin, director of the Center for Minimally Invasive Surgery at Ohio State University, Columbus.
The difficulty of the procedure has contributed to a substantial rate of intraoperative esophageal perforations, which occurred in 51 (11%) of 479 laparoscopic Heller myotomies performed for achalasia in all series reported during the past 7 years.
To assess robotic Heller myotomy as an achalasia treatment, Dr. Melvin and his colleagues conducted a prospective study of 104 patients treated with the da Vinci robotic surgery system (made by Intuitive Surgical Inc.) and partial fundoplication at three centers in 2000-2004. Only patients with previous surgical myotomy were excluded from the study. The patients' hospital stay averaged 1.5 days.
No esophageal perforations occurred intraoperatively or postoperatively. Eight minor complications occurred, including urinary retention and postoperative pyrexia, Dr. Melvin said. One patient needed conversion to an open surgery because of bleeding, and another to a standard laparoscopic surgery because the robotic system failed.
No reoperative procedures were necessary in 79 patients who had an average follow-up of 16 months. According to a survey completed by these 79 patients, symptoms improved from a mean score of 5 prior to surgery to 0.48 during the follow-up period.
The hardest part of the computer-assisted surgery often was at the gastroesophageal junction, where some patients had scarring from undergoing previous therapies such as Botox injection or balloon dilatation, Dr. Melvin said.
The operative time for the computer-assisted surgery at first averaged 162 minutes but fell to 113 minutes in the study's last 2 years.