Robotic-assisted laparoscopic Heller-Dor?s cardiomyotomy and fundoplication for achalasia

Introduction: The outcomes of surgical interventions for achalasia treatment improved with the advent of minimally invasive surgery. Robotic-assisted Heller-Dor's (RAHD) procedure established over the last years, provides impor-tant advantages to surgeons, such as binocular three-dimensional vision and improvement of fine motor control.Method: Between October and December of 2022, first in Hungary, 3 patients (37-year-old man, 55-and 72-year -old women) underwent RAHD procedure for achalasia at the Clinical Centre of the University of Pecs using the da Vinci Xi system.Results: RAHD procedure was feasible without any particular problems and the postoperative course of all three patients was uneventful. The operation times were 198, 204 and 238 minutes, including 23, 19 and 14 minutes for the setup time of the robot. By the last patient, due to an accompanying hiatal hernia, an additional hiatal reconstruc-tion was also performed. In the first 2 cases, the patients were discharged on the 4th postoperative day, while in the last case, with the additional hiatal reconstruction, the patient was emitted on the 6th postoperative day.Discussion: There are several published studies about RAHD cardiomyotomy. The general conclusion is that, in ex-perienced hands, RAHD procedure is easy to perform, ensures a meticulous esophageal and gastric myotomy, allow-ing to visualize and divide each muscle fiber with a significantly lower rate of mucosal perforations. However, by RAHD procedure, the overall costs are higher, including a longer operation time during the learning curve. At the same time, the avoidance of mucosal lacerations and their possible consequences has to be weighed against the higher overall costs.Conclusion: Laparoscopic cardiomyotomy is the first standard upper-gastrointestinal operation where a clear advan-tage of the use of a surgical robot has been proven. Thus, wherever this equipment is available, it should be preferred for this procedure.