Laparoscopic robotic-assisted Heller procedure for esophageal achalasia

This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.

Créer un compte gratuit

l'Université Virtuelle

Google translate

Résumé
Chapitres
Vos Commentaires
Interrogez les Experts

Vous devez vous identifier pour accéder à cette partie du site !

Laparoscopic robotic-assisted Heller procedure for esophageal achalasia

Authors

Abstract

This video demonstrates a robotic-assisted Heller procedure for treatment of esophageal achalasia. The surgeon starts by dissecting the gastroesophageal junction. The mobilization of the stomach is limited to the anterior and lateral aspect, leaving the posterior attachments intact. The myotomy is started just above the gastroesophageal junction and extended 6 cm proximally and 2 cm distally onto the stomach using robotic articulated scissors. The extension of the myotomy on the gastric side continues to be the most difficult part of the dissection. The change in direction of the muscular fibers, from circular at the esophagus, to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers. The video demonstrates the freedom of movement of the articulated robotic instruments that allow the surgeon to divide each individual muscular fiber achieving a precise dissection of the gastroesophageal junction. Once the myotomy is completed a standard Dor Fundoplication is performed.

Catégorie

complex cases, robotic

Mots-clés

Robotic-assisted Heller myotomy, Heller procedure, esophageal achalasia

Type de vidéo

Vidéo chirurgicale

Durée

12'15''

Publication

2006-10

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Oct 2006;6(10).
URL: http://www.websurg.com/doi-vd01en2007.htm

Laparoscopic robotic-assisted Heller procedure for esophageal achalasia

1. Trocar placement 00'16''

The set-up of the robot usually is performed by the assistant at the bedside. The assistant is in charge of cutting, suction, and retraction.

2. Robotic set-up 00'30''

Also, if needed, the assistant switches the robotic instruments for the operating surgeon.

3. Start of procedure 00'41''

We started by dissecting the gastroesophageal junction, which is exposed gently retracting the liver. The gastro-hepatic ligament is divided and the right crus is identified. Only the anterior part of the esophagus will be dissected, respecting the posterior attachments. The fat pad is removed for better exposure of the gastroesophageal junction. Once identified, the crus is then separated by blunt dissection from the esophagus. The dissection is gently carried out from the right to the left.

4. Dissection of crura and esophagus 02'30''

The peritoneum and phreno-esophageal membrane are divided and the left crus is identified. The left crus is now separated from the esophagus. The dissection is extended above the gastroesophageal junction. The residual fat is removed to visualize the GE junction. The myotomy is started just above the gastroesophageal junction at the 12 o’clock position using the robotic articulated scissors. The anterior branch of the vagus nerve is mobilized from the esophageal wall. The vagus is gently retracted towards the left. The esophageal part of the myotomy is done with scissors. Careful dissection allows a good protrusion of the esophageal mucosa. All muscular fibers are divided to ensure completeness of the myotomy. The extension of the myotomy onto the gastric side continues to be the most difficult part of the dissection.

5. Myotomy 05'34''

The change in direction of the muscular fibers, from circular at the esophagus to oblique at the stomach, makes it difficult to develop the necessary submucosal plane for dividing the muscular fibers, and bleeding is more likely. The freedom of movement of the articulated instruments and the three-dimensional vision allow the surgeon to visualize and divide each individual muscular fiber, ensuring an adequate myotomy. This along with tremor control allows accurate dissection of the gastroesophageal junction, offering a clear view of the submucosal plane and reducing the risk of perforation. Here the robotic arm allows a range of motion with the left hand that is impossible to reproduce in laparoscopy. The assistance of the robotic system overcomes the natural impediments of laparoscopic surgery and a precise dissection of the GE junction can be performed with the left hand. The 8cm long myotomy is now completed. The short gastric vessels are routinely divided. This step is done with a hook beginning midway along the greater curvature and extended up to the angle of His. The preferred anti-reflux operation is the Dor fundoplication, which is both simple and effective. The Dor fundoplication is an anterior 180° wrap and involves two rows of sutures, each consisting of three stitches.

6. Dor fundoplication 08'30''

The first row of sutures incorporates the gastric fundus, the left crura, and the left side of the myotomy. The gastric fundus nicely mobilized is then folded over the myotomy and a second row of sutures is placed between the stomach, the right crura, and the right side of the myotomy. The two uppermost stitches incorporate the gastric fundus and the right crura. The third and last stitch incorporates the stomach, the right crura, and the right side of the esophageal wall. This last stitch completes our wrap. According to different techniques, additional stitches can be placed between the anterior rim of the hiatus and the superior aspect of the fundoplication. The issue of the best operation for achalasia has been a matter of debate focusing mainly on the extent of the myotomy and on the type of anti-reflux operation. Extension of the myotomy upward on the lower third of the esophagus is seldom responsible for a persistent dysphagia. On the contrary, this is a predictable consequence when the myotomy is not sufficiently long at a distal end. The extension of the myotomy for about 2 centimeters to the gastric wall eliminates the risk of persistent dysphagia. We routinely perform an anterior Dor fundoplication because it can be done without posterior dissection and covers the exposed esophageal mucosa.