I would like to express my sincere gratitude to Dr. DuCoin for the opportunity to study robotic foregut surgery. As a research fellow from Israel, I am grateful for the opportunity to share this robotic approach to the Heller myotomy used at our center. The authors received no funding for this work.

This protocol follows the guidelines of our institution&#39;s human research ethics committee. Written informed consent was obtained from the patients&#39; cases reviewed for the protocol. Inclusion criteria - patients of all ages who were diagnosed with achalasia based on clinical manifestations, manometric criteria, and radiographic studies. Exclusion criteria - achalasia symptoms due to gastroesophageal malignancy.
1. Preoperative preparation
<ol>
	<li>Place patients on a liquid diet for 3 days prior to the operation in an attempt to clear the esophagus of impacted food.</li>
	<li>Place the patient in the supine position and administer general endotracheal anesthesia (GETA) via a rapid sequence induction (RSI) while holding cricothyroid pressure to reduce the risk of aspiration during intubation. To provide Cricothyroid pressure, apply manual pressure on the cricoid cartilage to occlude the esophagus. 
	NOTE: The RSI technique is conducted via the administration of appropriate anesthetic agents and neuromuscular blocking agents per the anesthesiologist&#39;s protocol.</li>
	<li>After successful endotracheal intubation, perform an esophagogastroduodenoscopy (EGD) to assess the level of achalasia severity and dislodge any solid food stuck in the esophagus, if needed (Figure 1A).
	<ol>
		<li>Ensure the endoscope is clean and properly connected to the video monitor and light source. Confirm that the water and air channels are functioning correctly, lubricate the distal end of the endoscope to facilitate insertion, and then gently insert the endoscope through the patient&#39;s mouth into the esophagus under direct visualization. 
		NOTE: Usually, there is a pop of pressure as the endoscope is passed through the gastroesophageal junction with pressure.</li>
	</ol>
	</li>
	<li>Leave the endoscope in the stomach to function as a bougie and provide counter pressure within the esophagus during the myotomy procedure.</li>
</ol>
2 Ports placement and robotic docking
NOTE: A total of four 8 mm robotic ports are required for the surgery, and there is an option to add a fifth port to serve as an assistant trocar.
<ol>
	<li>Following skin sterilization and preparation using an antiseptic solution, perform a small skin incision of approximately 1 cm using a blade at each planned trocar insertion site in order to insert the trocar into the abdominal cavity.</li>
	<li>Place the first port site at 15 cm below the xiphoid process, 1-2 cm to the left of the abdominal mid-line, using a 0&#176; 5 mm laparoscope and optical access trocar visualization technique. Use a verses needle to inflate the abdomen when needed.</li>
	<li>Attach carbon dioxide gas insufflation and inflate the abdomen to 15 mmHg. Reinsert the 0&#176; scope and inspect the abdomen for any site of potential trocar injury. Change the laparoscope to 30&#176; to facilitate additional trocar placement.</li>
	<li>Under direct vision, place three 8 mm robotic trocars in a transverse line at the level of the first port with 4-8 cm between each port (try to leave 8 cm between each port to reduce collisions within the robotic arms). Locations of robotic ports (from patient left to right) are approximately at the left anterior axillary line, left mid-clavicular line, and right mid-clavicular line (Figure 2).</li>
	<li>Place an additional assistant trocar in the right flank at the level of the right anterior axillary line, just above the level of the umbilicus.</li>
	<li>Place a Nathanson liver retractor in the xiphoid region to elevate the left lateral lobe of the liver and expose the hiatus. This will expose the entire left upper quadrant, ensuring excellent exposure for the operation.</li>
	<li>Dock the robot. Prepare the instruments, which include an advanced bipolar energy device, a cardia forceps, a fenestrated bipolar, and a hook cautery.</li>
</ol>
3 Division of phren-oesophageal ligament
<ol>
	<li>Divide the gastrohepatic ligament using the bipolar energy device to expose the right crus and phren-oesophageal membrane (Figure 3).</li>
	<li>Identify the phreno-esophageal membrane and divide it using the bipolar energy device toexpose the longitudinal muscle fibers of the esophagus. Extend and dissect the avascular plane between the esophagus and mediastinum from the right crus to the left crus after dividing the phren-oesophageal ligament.This dissection should expose the anterior surface of the esophagus.</li>
	<li>Identify and preserve the anterior vagus nerve. Elevate and dissect the anterior vagus nerve off of the esophagus to facilitate the preservation of the nerve and to ensure a complete myotomy beneath the nerve .</li>
</ol>
4 Esophageal myotomy
<ol>
	<li>Dissect the gastroesophageal fat pad on the anterior surface using an electrocautery hook from the level of the stomach to expose the GEJ; start the dissection at the distal fat pad.</li>
	<li>Extend the dissection proximally to the left crus using an electrocautery hook, and then medially dissect towards the right crus with care to preserve and protect the anterior vagus, which often courses through the medial aspect of the fat pad.</li>
	<li>Before performing the myotomy, completely expose the distal portion of the esophagus and the anterior portion of the proximal stomach to allow for the appropriate length of myotomy. 
	NOTE: The goal for myotomy length should be a minimum of 6 cm in the distal esophagus and 2 cm in the proximal stomach.</li>
	<li>Begin the myotomy just proximal to the GEJ on the side of the esophagus, approximately 1 cm proximal. This approach will help the surgeon avoid the sling fibers of the stomach, which can occasionallycause confusion during dissection.</li>
	<li>Exchange the robotic advanced bipolar instrument for the robotic hook. With great care, start the myotomy 1 cm proximal to the GE junction with a brief application of cautery energy with the robotic hook. Using traction of the robotic hook towards the anterior abdominal wall, carefully divide the esophageal muscle fibers until the esophageal mucosa is visualized.</li>
	<li>After the mucosa is visualized, repeat the traction motion of the hook (with minimal use of cautery) to tear the esophageal muscular fibers proximally onto the esophagus. Continue dissection until either the view becomes obstructed or the dissection has reached a point where repairing an injury would be challenging. Ensure that it is at least 6 cm in length (Figure 4 and Figure 5).</li>
	<li>After completing the proximal myotomy, continue the dissection down onto the side of the stomach. 
	NOTE: A technical consideration during myotomy is to prioritize the tearing of muscle fibers rather than using cautery. This helps to minimize the risk of thermal injury. However, if cautery is used, it is recommended to pull the circular fibers away from the esophagus before applying cautery. (Figure 4)</li>
</ol>
5 Post-myotomy esophago-gastro-duodenoscopy
<ol>
	<li>Perform an EGD to evaluate the GEJ. Ensure that the endoscope easily passes across the cardia and use visual inspection to ensure that there is no thermal injury (Figure 1B).</li>
	<li>Perform a leak test by inflating the esophagus and stomach with air while submerging them in water. Evaluate for the presence of gas bubbles, which could indicate a leak.</li>
	<li>After completing the myotomy,proceed with a Dor to Toupet fundoplication if indicated. 
	NOTE: If a Toupet fundoplication is performed, posterior dissection of the hiatus is necessary. However, if a Dor fundoplication is to be performed, there is no need to disturb the posterior attachments of the esophagus.</li>
	<li>Upon completing the procedure, remove the endoscope along with the liver retractor and ports.</li>
</ol>
6 Post-operative care
<ol>
	<li>In the postoperative period, administer a multi-modal pain regimen with anti-inflammatory and opioid medications. Start patients with a clear liquid diet on the day of surgery. On postoperative day 1, perform a radiographic evaluation with an upper GI series to evaluate for leaks (Figure 6B). Most patients are discharged on postoperative day 1 with instructions to follow a full liquid diet until post-operative evaluation in the surgery clinic within 2 weeks.</li>
</ol>

Treatment of Achalasia by Robot-Assisted Heller Myotomy

<ol>
	<li>Boeckxstaens, G. E., Zaninotto, G., Richter, J. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Achalasia.">Achalasia.</a> Lancet. 383, 83-93 (2014).</li><li>Goyal, R. K., Chaudhury, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pathogenesis+of+achalasia:+lessons+from+mutant+mice.">Pathogenesis of achalasia: lessons from mutant mice.</a> Gastroenterology. 39 (4), 1086-1090 (2010).</li><li>Leeuwenburgh, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+esophageal+cancer+risk+in+patients+with+primary+achalasia:+a+prospective+study.">Long-term esophageal cancer risk in patients with primary achalasia: a prospective study.</a> Am J Gastroenterol. 105 (10), 2144-2149 (2010).</li><li>Campos, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+and+surgical+treatments+for+achalasia:+a+systematic+review+and+meta-analysis.">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li><li>Lopushinsky, S. R., Urbach, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pneumatic+dilatation+and+surgical+myotomy+for+achalasia.">Pneumatic dilatation and surgical myotomy for achalasia.</a> JAMA. 296 (18), 2227-2233 (2006).</li><li>Yaghoobi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Heller's+myotomy+versus+pneumatic+dilation+in+the+treatment+of+idiopathic+achalasia:+a+meta-analysis+of+randomized,+controlled+trials.">Laparoscopic Heller's myotomy versus pneumatic dilation in the treatment of idiopathic achalasia: a meta-analysis of randomized, controlled trials.</a> Gastrointest Endosc. 78 (3), 468-475 (2013).</li><li>Boeckxstaens, G. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pneumatic+dilation+versus+laparoscopic+Heller's+myotomy+for+idiopathic+achalasia.">Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia.</a> N Engl J Med. 364 (19), 1807-1816 (2011).</li><li>Patti, M. G., Schlottmann, F., Herbella, F. A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+Heller+myotomy+and+robotic+Heller+myotomy:+when+is+it+indicated.+Mini-invasive.">Laparoscopic Heller myotomy and robotic Heller myotomy: when is it indicated. Mini-invasive.</a> Surgery. 6, 38 (2022).</li><li>Campos, G. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+and+surgical+treatments+for+achalasia:+a+systematic+review+and+meta-analysis.">Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.</a> Ann Surg. 249 (1), 45-57 (2009).</li><li>Maeso, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+the+Da+Vinci+surgical+system+in+abdominal+surgery+compared+with+that+of+laparoscopy:+a+systematic+review+and+meta-analysis.">Efficacy of the Da Vinci surgical system in abdominal surgery compared with that of laparoscopy: a systematic review and meta-analysis.</a> Ann Surg. 252 (2), 254-262 (2010).</li><li>Huffmanm, L. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic+Heller+myotomy:+a+safe+operation+with+higher+postoperative+quality-of-life+indices.">Robotic Heller myotomy: a safe operation with higher postoperative quality-of-life indices.</a> Surgery. 142 (4), 613-618 (2007).</li></ol>

Dr. DuCoin works for Intuitive Surgical, Medtronic, and Johnson &amp; Johnson. The other authors declare no competing interests.

Laparoscopic and robotic Heller myotomy is now the procedure of choice with or without fundoplication6. The primary contentious issues revolve around the necessity of fundoplication after Heller myotomy, as well as the type of fundoplication (Toupet, Dor, Nissen) to minimize GERD. Peroral endoscopic myotomy (POEM) is another option for achalasia treatment; however, this option lacks a fundoplication procedure8. Therefore, surgeons should make decisions regarding which procedures to perform based on their own experience and preferences. The critical point in myotomy is to obtain enough length of myotomy on both the esophageal and gastric sides. The gastric side myotomy is, at times, more challenging than the esophageal myotomy as there is now a serosal layer of the stomach wall, and the gastric sling fibers are present as well. During this dissection, it is also common to encounter large submucosal veins feeding into the left gastric venous system. If bleeding is encountered, it is recommended to use pressure and a thrombotic agent to stop the bleeding. Additionally, caution should be taken while using hook cautery to avoid injury to the esophageal mucosa and to prevent perforation9. If there are issues with exposure of the mediastinum during esophageal myotomy, the anterior portion of the diaphragmatic hiatus can be divided to increase exposure. However, if this is done, this should be closed with a permanent stitch at the completion of the case.
The advantages of robotic surgery compared to others are enhanced dexterity and greater precision due to better visualization with the three-dimensional view. Additionally, it gives the surgeon the ability to operate even in tight spaces, hence its utilization in pelvic surgery. A meta-analysis study showed a lower intra-operative perforation rate with robotic Heller myotomy compared to laparoscopic surgery (0% vs. 11%, respectively)10. The disadvantage of the robotic approach is reported higher cost11. The limitations of the laparoscopic approach include a poor range of motion and limited view and visual stability when compared to robotics.
In conclusion, in the hands of experienced surgeons, robotic surgery is safer and yields exceptional results due to its improved visualization, platform stability, and increased articulation of the instruments.

Achalasia is an esophageal motility disorder. The most common cause of achalasia is idiopathic, characterized by impairment of the circular and longitudinal muscular layers of the esophagus due to the destruction of the myenteric nerves in the lower esophageal sphincter (LES)1. This leads to the inability of the LES to relax. Achalasia is also associated with an increased risk of esophageal squamous cell carcinoma. The gold standard for diagnosing achalasia is manometry2,3. However, endoscopy should be performed to rule out other causes of narrowing, such as gastro esophageal junction (GEJ) malignancy and other strictures.
The treatment of achalasia is divided into surgical and non-surgical options. Non-surgical treatments include the use of drugs such as calcium channel blockers and nitrates, as well as endoscopic treatments like dilation or botulinum toxin injection. Non-surgical treatments have high recurrence rates4,5. Surgical treatment, specifically laparoscopic or robotic myotomy, originally described as the heller myotomy, can be performed with or without an anti-reflux procedure. Surgical treatment provides the best long-term treatment and relieves achalasia symptoms by dissection of the muscles in the affected part of the esophagus around the LES6.
The decision to perform a fundoplication following Heller myotomy remains controversial. In theory, anti-reflux procedures, such as the Dor or Toupet procedures, reduce the risk of gastroesophageal reflux disease (GERD) following myotomy. Peroral endoscopic myotomy (POEM) has been developed as an option in the treatment of achalasia. Through a proximal submucosal tunnel, the muscular layer of the affected esophagus is divided distally to the level of LES and cardia7. We perform the Heller myotomy using a robotic approach. The robotic platform offers enhanced high-definition visualization of distal esophageal and hiatal anatomy, advanced range of motion, and decreased complication rates when compared to the laparoscopic approach8. Despite all the advantages of the robotic approach, the method and approach to surgical treatment of achalasia decision ultimately lies with the surgeon and is dependent on the available resources, level of comfort, and experience with the available techniques. The goal of this protocol is to serve as a guide and a valuable resource for training new foregut surgeons, as well as residents, making the steps of the surgery clear and understandable.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>8 mm assistance port</td>
			<td>Da Vinci</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Air Seal insuflation system</td>
			<td>CONMED</td>
			<td>Ias8-120LP</td>
			<td></td>
		</tr>
		<tr>
			<td>Force bipolar grasper</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Forceps</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Four 8-mm robotic ports</td>
			<td>Da Vinci</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hook cautery.&#160;</td>
			<td>COVIDIEN</td>
			<td>E3773-36C</td>
			<td></td>
		</tr>
		<tr>
			<td>Nathanson liver retractor</td>
			<td>Mediflex</td>
			<td>69704-3</td>
			<td></td>
		</tr>
		<tr>
			<td>Needle driver</td>
			<td>COVIDIEN</td>
			<td>172015</td>
			<td></td>
		</tr>
		<tr>
			<td>Robotic 30&#176; endoscope</td>
			<td>Da Vinci</td>
			<td>470057</td>
			<td></td>
		</tr>
		<tr>
			<td>Robotic advanced bipolar device (Vessel Sealer)</td>
			<td>INTUITIVE SURGICAL</td>
			<td>480422</td>
			<td></td>
		</tr>
		<tr>
			<td>Two laparoscopic graspers</td>
			<td>Stortv</td>
			<td></td>
			<td></td>
		</tr>
	</tbody>
</table>

robotic heller myotomy for advancements in surgical management of achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the failure of the LES to relax. Patients typically complain of dysphagia, chest pain, and regurgitation. They often report drinking liquids with solids intake to help propel food boluses into the stomach. The diagnosis of achalasia is typically confirmed with an esophagogram and a motility study (esophageal manometry). An esophagogram classically shows the bird beak sign with tapering in the distal esophagus. The treatment for achalasia includes both surgical and non-surgical options. Surgical treatment is associated with a lower rate of recurrences, high clinical success rate, and durability of symptom relief. The current gold standard of surgical technique is myotomy, or the dividing of the muscle fibers of the distal esophagus. Surgical myotomy can be accomplished via a laparoscopic or robotic technique; per-oral endoscopic myotomy is a new alternative intervention. Due to the theoretical risk of gastroesophageal reflux following a myotomy, an antireflux procedure is sometimes performed. We reviewed the approach to a robotic heller myotomy for the treatment of achalasia.

At our academic tertiary care center, both intraoperative and postoperative complications of Heller myotomy are extremely rare. Between 2020 and August 2023, post-Heller myotomy perforation rate was 0% utilizing the robotic approach. During this period, we performed 105 robotic Heller myotomy. Blood loss is generally less than 20 mL, and we did not transfuse blood for any patient; hospital stay length rarely exceeds postoperative day 1, and patients are able to drink immediately after surgery, experiencing relief of their achalasia symptoms. After the myotomy, we routinely perform intraoperative esophagogastroduodenoscopy (EGD) to evaluate the gastroesophageal (GE) junction. During this examination, we ensure that the endoscope can easily pass across the cardia (Figure 1B), and we can rule out any injury using a leak test. In recent years, we have begun to utilize endoluminal functional lumen imaging probes during the operation. Our patient was chosen randomly. She is a 67-year-old with a history of psoriatic arthritis and type II Achalasia. She had been suffering from progressive dysphagia, even after a previous attempt to treat it with Botox and dilation. The procedure (Heller myotomy) was performed successfully without any complications, and no blood transfusions were needed. She was able to drink immediately after the procedure and felt obvious relief from the dysphagia. After the surgery, she was discharged home on postoperative day 1. These results following surgery allow us to be confident of a safe and complete myotomy (Table 1). The radiographic evaluation of the upper GI series done before the operation and on post-operative day 1, showing the removal of the strictures and the absence of any leaks, is depicted in Figure 6.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66224/66224fig01.jpg" /> 
Figure 1: Esophagogastroduodenoscopy. (A)&#160;Preoperative esophagogastroduodenoscopy (EGD) was used to visualize the severity of achalasia and rule out other findings (GEJ malignancy and other strictures). (B) Post-myotomy esophagogastroduodenoscopy (EGD) was able to pass the endoscope across the cardia easily, and no thermal injury was found. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66224/66224fig02.jpg" /> 
Figure 2: Trocars placement. From the patient&#39;s left to right, the picture depicts the arrangement of 4 robotic trocars spaced approximately 8 cm apart. In addition, there is an assistant trocar positioned at the level of the right anterior axillary line. Furthermore, a Nathanson liver retractor is visible in the xiphoid region. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66224/66224fig03.jpg" /> 
Figure 3: Gastrohepatic ligament division. Division of the Gastrohepatic ligament, exposing the right cruse and phren-oesophageal membrane, using the bipolar energy device. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66224/66224fig04.jpg" /> 
Figure 4: Esophageal myotomy. The picture shows the application of traction using a robotic hook towards the anterior abdominal wall while carefully separating the muscle fibers of the esophagus until the esophageal mucosa becomes visible. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/66224/66224fig05.jpg" /> 
Figure 5: Complete esophageal myotomy. The picture illustrates a complete esophageal myotomy spanning at least 6 cm, highlighting the preservation of the anterior Vagus nerve branch indicated by an arrow. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/66224/66224fig06.jpg" /> 
Figure 6: Upper GI series. (A) This picture demonstrates a dilated esophagus and an EGJ stricture after ingesting barium during a GI series. (B) Following Heller myotomy, we can observe a significant relief in esophageal dilation and a significant improvement of the GEJ stricture with the passage of barium. Additionally, no evidence of a leak or free air was found. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/66224/66224fig06large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Age</td>
			<td>67 years</td>
		</tr>
		<tr>
			<td>Gender</td>
			<td>Female</td>
		</tr>
		<tr>
			<td>Race</td>
			<td>White or Caucasian</td>
		</tr>
		<tr>
			<td>BMI</td>
			<td>40</td>
		</tr>
		<tr>
			<td>Intraoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Operative time, min</td>
			<td>160 min</td>
		</tr>
		<tr>
			<td>Intraoperative blood loss, mL</td>
			<td>20 mL</td>
		</tr>
		<tr>
			<td>Postoperative</td>
			<td></td>
		</tr>
		<tr>
			<td>Postoperative complications</td>
			<td>None</td>
		</tr>
		<tr>
			<td>Hospital length of stay, days</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Discharge, postoperative day (POD)</td>
			<td>POD 1</td>
		</tr>
	</tbody>
</table>
Table 1: Patient demographic and operation parameters.

Read this Scientific Article Protocol about Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia at JoVE.com

Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia.

Robotic Heller Myotomy for Advancements in Surgical Management of Achalasia

Achalasia is an esophageal motility disorder. It occurs due to the destruction of nerves in the lower esophageal sphincter (LES), which leads to the ...

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511 Views.  University of South Florida. The protocol presents a robotic approach to Heller myotomy for the treatment of achalasia. 

Video: Author Spotlight: Cutting-Edge Robotic Heller Myotomy Protocol for Treatment of Achalasia

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Meatal stenosis is a common urologic complication after circumcision.  Children present to their primary care physicians with complaints of deviated ...

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is respect for patient's values, preferences, and expressed needs. Yet specific approaches to gaining this understanding and translating it to quality care in the clinical setting are lacking. From a patient perspective quality is not a simple concept but is best understood in terms of five dimensions: technical outcomes; decision-making efficiency; amenities and convenience; information and emotional support; and overall patient satisfaction. Failure to consider quality from this five-pronged perspective results in a focus on medical outcomes, without considering the processes central to quality from the patient's perspective and vital to achieving good outcomes. In this paper, we argue for applying the concept of fair process in clinical settings. Fair process involves using a collaborative approach to exploring diagnostic issues and treatments with patients, explaining the rationale for decisions, setting expectations about roles and responsibilities, and implementing a core plan and ongoing evaluation. Fair process opens the door to bringing patient expertise into the clinical setting and the work of developing health care goals and strategies. This paper provides a step by step illustration of an innovative visual approach, called photovoice or photo-elicitation, to achieve fair process in clinical work with acquired brain injury survivors and others living with chronic health conditions. Applying this visual tool and methodology in the clinical setting will enhance patient-provider communication; engage patients as partners in identifying challenges, strengths, goals, and strategies; and support evaluation of progress over time. Asking patients to bring visuals of their lives into the clinical interaction can help to illuminate gaps in clinical knowledge, forge better therapeutic relationships with patients living with chronic conditions such as brain injury, and identify patient-centered goals and possibilities for healing. The process illustrated here can be used by clinicians, (primary care physicians, rehabilitation therapists, neurologists, neuropsychologists, psychologists, and others) working with people living with chronic conditions such as acquired brain injury, mental illness, physical disabilities, HIV/AIDS, substance abuse, or post-traumatic stress, and by leaders of support groups for the types of patients described above and their family members or caregivers.

This paper illustrates an innovative visual approach (photovoice or photo-elicitation) to achieve fair process in clinical care for patients living with chronic health conditions, illuminate gaps in clinical knowledge, forge better therapeutic relationships, and identify patient-centered goals and possibilities for healing.

The Institute of Medicine has targeted patient-centeredness as an important area of quality improvement. A major dimension of patient-centeredness is ...

Remote Magnetic Navigation for Accurate, Real-time Catheter Positioning and Ablation in Cardiac Electrophysiology Procedures

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac substrates such as left atrial flutter. This protocol describes all the clinical and invasive interventional steps performed during a human electrophysiological study and ablation to assess the accuracy, safety and real-time navigation of the Catheter Guidance, Control and Imaging (CGCI) system. Patients who underwent ablation of a right or left atrium flutter substrate were included. Specifically, data from three left atrial flutter and two counterclockwise right atrial flutter procedures are shown in this report. One representative left atrial flutter procedure is shown in the movie. This system is based on eight coil-core electromagnets, which generate a dynamic magnetic field focused on the heart. Remote navigation by rapid changes (msec) in the magnetic field magnitude and a very flexible magnetized catheter allow real-time closed-loop integration and accurate, stable positioning and ablation of the arrhythmogenic substrate.

This report provides a detailed description of a new remote navigation system based on magnetic driven forces, which has been recently introduced as a new robotic tool for human cardiac electrophysiology procedures.

New remote navigation systems have been developed to improve current limitations of conventional manually guided catheter ablation in complex cardiac ...

Therapeutic Effectiveness of a Dietary Supplement for Management of Halitosis in Dogs

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized placebo-controlled crossover clinical evaluation, we assessed&#160;the effectiveness of a dedicated dietary supplement to improve chronic halitosis in 32 dogs of different breeds and ages. This protocol describes how to evalute the presence of oral volatile suphur compunds, e.g. methyl mercaptan, hydrogen sulfide and dimethyl sulfide, by means of a portable gas chromatograph device coupled with a syringe, which was used to collect the breath, and a dedicated software, which allows the operator to monitor each compound concentration during each measurement, in a relatively short time (8 min).
A significant modification of halitosis parameters was observed after 30 days since the beginning of treatment (p &#60;0.05), while a long-lasting effect was still observed even 20 days after the suspension of the treatment. Portable gas chromatograph, which is also widely used in clinical practice, can be therefore used to confirm&#160;and control halitosis in humans and animals. Even though human and animal species present some differences,&#160;this innovative and alternative therapy for halitosis management might be extended to human clinical practice as an adjuvant dietary approach.

We describe a simple approach for diagnosis of halitosis in dogs as well as a dietary approach for its management. This protocol may be extended to the management of halitosis in humans in the near future.

Halitosis is a common complaint involving social and communicational problems in humans and also affects the pet-owner relationship. In this randomized ...

Application of End-to-end Anastomosis in Robotic Central Pancreatectomy

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of pancreatic body. With technological development, the robotic surgical system has shown its advantage in minimally invasive surgery and been increasingly applied in central pancreatectomy. However, reconstruction of the continuity of pancreas with end-to-end anastomosis after robotic central pancreatectomy has not been applied. In this study, we report surgical techniques for robotic central pancreatectomy with end-to-end anastomosis. The pancreas is reconstructed by duct-to-duct anastomosis of the pancreatic duct with a pancreatic stent inserted in the two stumps of pancreatic duct, and by end-to-end anastomosis of the pancreatic parenchyma. Compared with traditional central pancreatectomy with pancreaticoenteric anastomosis, this approach decreases the operative injury to the patient, and also conserves the integrity and continuity of the digestive duct and pancreatic duct. The robotic surgical system integrated with multiple instruments with flexible and precise movement is particularly suitable for the dissection and reconstruction of the pancreatic duct. We found that robotic central pancreatectomy with end-to-end anastomosis is safe and feasible, and we need more experience to evaluate its best indications and long-term outcomes.

The robotic central pancreatectomy with end-to-end anastomosis is feasible and safe for tumor in the pancreatic neck and proximal portion of pancreatic body. The operative techniques of this operation are presented.

Central pancreatectomy is carried out for the treatment of benign or low-malignant potential tumors located in the pancreatic neck or proximal part of ...

Robotic Lateral Pancreaticojejunostomy for Chronic Pancreatitis

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The recent rise of robotic and laparoscopic pancreatic surgery has found benefits such as reduced time to functional recovery. Few studies have reported on the feasibility, technique and outcome of robotic LPJ, especially including transection of the gastroduodenal artery. The present study describes the main steps for robotic LPJ in a patient with painful chronic pancreatitis with a dilated main pancreatic duct. The patient underwent robotic LPJ. The LPJ anastomosis is performed using a running suture technique in a longitudinal side-to-side manner. Routinely, the gastroduodenal artery is transected to drain the entire length of the main pancreatic duct. The patient is in French position; 7 trocars are placed (4 robotic, 2 laparoscopic assistants, 1 liver-retractor). After docking of the robot system, the omental bursa is opened, and the right gastroepiploic artery and vein are ligated at their base at the lower border of the pancreas. Intraoperative ultrasonography is performed in order to determine trajectory of the dilated main pancreatic duct which is opened for its entire length after the gastroduodenal artery has been suture ligated both cranially and caudally from the main pancreatic duct. A Roux limb is created, and a latero-lateral PJ is fashioned using several 3-0 barbed sutures. A stapled jejuno-jejunostomy is created at sufficient distance from the pancreatic anastomosis, aided by a 50 cm suture. The described technique for robotic LPJ is a complex but feasible operation for patients with treatment refractory CP and a dilated main pancreatic duct. Due to its complexity, implementation in high volume centers with extensive experience with CP surgery may improve outcomes.

Robotic lateral pancreaticojejunostomy (RLPJ) may be used in patients with painful, morphine dependent, chronic pancreatitis and a dilated main pancreatic duct. We describe a standardized and reproducible technique for RLPJ, which includes transection of the gastroduodenal artery.

Lateral pancreaticojejunostomy (LPJ) has shown good postoperative outcomes in patients with painful, morphine dependent, chronic pancreatitis (CP). The ...

Sleeve Gastrectomy in Mice using Surgical Clips

The number of people who are overweight and obese is continually increasing both in the adult and adolescent populations. This coincides with the increased universal phenomenon of type 2 diabetes (T2D) and other metabolic problems. Bariatric surgery, such as SG, is currently one of the most effective and commonly used long-term treatment for obesity and T2D, but the association between them is not completely explored yet. The mechanisms underlying the outcomes seen after bariatric surgery in humans can be investigated based on preclinical animal studies. The SG reduces body weight, glucose levels and many metabolic parameters, and is easy to perform with a low incidence of complications. The goal of this work is to provide a simple method and an uncomplicated preclinical model of bariatric surgery in animals for researchers.

The prevalence of diabetes and obesity is continuously increasing worldwide. The mechanisms between diabetes, obesity and their associated mortality and co-morbidities need to be further investigated. Here, we present a protocol for sleeve gastrectomy (SG) in animals as an uncomplicated preclinical model of bariatric surgery.

The number of people who are overweight and obese is continually increasing both in the adult and adolescent populations. This coincides with the ...

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US). Each method has limitations and advantages, including availability, ease of use, cost, size, and the use of ionizing radiation or magnetic fields. This protocol describes the use of 3D robotic US for in vivo imaging of rodent kidneys and heart, subsequent data analysis, and possible research applications. Practical applications of robotic US are the quantification of total kidney volume (TKV), as well as the measurement of cysts, tumors, and vasculature. Although the resolution is not as high as other modalities, robotic US allows for more practical high throughput data collection. Furthermore, using US M-mode imaging, cardiac function may be quantified. Since the kidneys receive 20%-25% of the cardiac output, assessing cardiac function is critical to the understanding of kidney physiology and pathophysiology.

Use of 3D Robotic Ultrasound for In Vivo Analysis of Mouse Kidneys

This protocol demonstrates robotic ultrasound (US) as a practical, cost-effective, and quick alternative to traditional non-invasive image modalities.

Common modalities for in vivo imaging of rodents include positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI), ...

Robotic Taj Mahal Hepatectomy for Hilar Cholangiocarcinoma

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In this study, a 32-year-old male patient with Bismuth Type IVa hilar cholangiocarcinoma underwent radical robotic resection of hepatic S4b, S5, and S1 (Taj Mahal hepatectomy) combined with regional lymphadenectomy, hilar bile duct reconstruction, and hepaticojejunostomy by the robotic surgical system. Postoperative pathological examination showed moderately-differentiated adenocarcinoma of the hilar bile duct. The surgical margins of the liver and bile ducts were negative. Recovery was smooth and the patient was discharged on the 17th postoperative day. The robotic surgical system and associated multiple instruments along with flexible and precise movements is suitable for the local hepatectomy around the porta hepatis, and delicate reconstruction of the hilar bile duct with a smaller diameter. This first clinical application study found that robotic Taj Mahal hepatectomy for hilar cholangiocarcinoma is safe and feasible and needs more experience for the evaluation of its long-term outcomes.

Robotic resection of hepatic S4b, S5, and S1 using the Taj Mahal procedure is feasible and safe for selected patients with hilar cholangiocarcinoma. The step-by-step details for this surgery are presented here.

Hilar cholangiocarcinoma is the most common malignant tumor of the biliary tract. Radical surgical resection is the only effective treatment option. In ...

Robotic Cochlear Implantation for Direct Cochlear Access

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of the clinical workflow for robotic cochlear implantation using a robotic system specifically developed for a minimally invasive, direct cochlear access. The clinical workflow involves experts from various disciplines and requires training to ensure a smooth and safe procedure. The protocol briefly summarizes the history of robotic cochlear implantation. The clinical sequence is explained in detail, beginning with the assessment of patient eligibility and covering surgical preparation, preoperative planning with the special planning software, drilling of the middle ear access, intraoperative imaging to confirm the trajectory, milling of the inner ear access, insertion of the electrode array, and implant management. The steps that require special attention are discussed. As an example, the postoperative outcome of robotic cochlear implantation in a patient with advanced otosclerosis is presented. Finally, the procedure is discussed in the context of the authors' experience.

Robotic cochlear implantation is a procedure for minimally invasive inner ear access. Compared to conventional surgery, robotic cochlear implantation involves additional steps that need to be carried out in the operating room. In this article we give a description of the procedure and highlight the important aspects of robotic cochlear implantation.

Robot-assisted systems offer great potential for gentler and more precise cochlear implantation. In this article, we provide a comprehensive overview of ...