Robotic telesurgery for achalasia

Abstract

The craft of surgery has always relied on the use of instruments. Innovations in surgery have paralleled innovations in instrumentation. Advances in surgical instrumentation continue today and have enabled huge strides in surgical procedures and outcomes during this generation. Computers and related technology are now changing the interface between the surgeon and the patient, and are poised to improve patient outcomes by enhancing the surgeon's skills and training. The application of computer enhanced telemanipulators, or "robots", may specifically enhance operations, for example Heller myotomy, that require good visualization and precise careful dissection of delicate structures. This review covers the pathophysiology of achalasia and its history of medical and surgical treatment, leading to modern robotic telesurgical approaches. Improvements in outcome from medical to standard surgical to robotic telesurgical approaches are discussed. Current operative technique for robotic telesurgical treatment of achalasia is described and the authors conclude with a glimpse of where, in the future, current research endeavors will lead us in the treatment of achalasia.

Keywords: Achalasia; Computer assisted; Heller myotomy; Robotic assistance.

Fig. 1

“Bird’s beak” appearance of lower esophagus during an upper gastrointestinal X-ray swallow study

Fig. 2

The da Vinci surgical robot in use with assistant surgeons alongside operative table

Fig. 3

The da Vinci surgical robot in use with head surgeon operating from the console

Fig. 4

Operative step of longitudinal esophageal myotomy using electrocautery. The rubber Penrose drain is used for retraction of the abdominal esophagus during this step

Fig. 5

Operative step of diaphragmatic posterior crural repair using robotic instrumentation. Note: the abdominal esophagus is coursing through the diaphragm in the top of the photograph

Fig. 6

Operative completion of the Heller myotomy and posterior 270° Toupet fundoplication