Evidence - Myotomy and Fundoplication according to Dor, robotically assisted

Introduction and Background

The laparoscopic Heller myotomy (LHM) is the gold standard for the surgical treatment of achalasia, a rare motility disorder of the esophagus. It was originally described in 1913 by Ernst Heller and later further developed through minimally invasive techniques (Rolinger et al., 2022). The procedure involves the division of the circular muscle fibers of the lower esophageal sphincter, often in combination with a partial fundoplication to reduce postoperative reflux (Schlottmann et al., 2018).

Results and Prognosis

• Long-term success rate: 80–90 % (Schlottmann et al., 2018)
• Improvement of dysphagia in 90 % of cases
• Reduction of regurgitation and chest pain
• Gastroesophageal reflux occurs in 10–30 % of cases (depending on the fundoplication technique) (von Rahden et al., 2014)
• Repeat or revision operations rare (<10 %)

Comparison with alternative therapy options

The peroral endoscopic myotomy (POEM) offers comparable success rates, but with a higher reflux risk, since no fundoplication is performed (Schlottmann et al., 2018). Pneumatic dilation is less invasive, but associated with a higher recurrence rate (Denzer et al., 2022).

Conclusion

• The laparoscopic Heller myotomy remains the gold standard for patients with achalasia who do not respond sufficiently to conservative measures.
• The combination with a fundoplication reduces the risk of postoperative reflux.
• Comparison with POEM: Higher reflux risk with POEM, but shorter recovery time.
• Future: Improvement of reflux prevention, individualized therapy approaches, optimization of patient-specific decision between LHM, POEM and dilation (Denzer et al., 2022).

Comparison of Robotic-Assisted and Laparoscopic Heller Myotomy in the Treatment of Esophageal Achalasia

The Heller myotomy is an established surgical therapy for esophageal achalasia. Traditionally, laparoscopic Heller myotomy (LHM) has been considered the standard treatment, while robotic-assisted Heller myotomy (RAHM) has increasingly been discussed as an alternative in recent years. Several studies and meta-analyses have compared both procedures in terms of safety, efficacy, and perioperative outcomes. Here, the most important findings are summarized:

1. Multicenter Study on RAHM vs. LHM

Horgan et al. (2005) conducted a multicenter study comparing RAHM with LHM. The results showed that both procedures achieved comparable improvement in symptoms, with the robotic-assisted technique associated with less muscle injury. However, the operation with the robot took longer than the laparoscopic method. The authors concluded that both procedures are safe and effective, with RAHM potentially offering advantages through more precise incision guidance.

2. Systematic Review and Meta-Analysis with Current Studies

A meta-analysis by Aiolfi et al. (2025) examined the existing studies on RAHM and LHM and concluded that the robotic-assisted technique was associated with shorter hospital stays and less postoperative pain. LHM, however, showed shorter OR times and lower costs. In terms of long-term outcomes, both procedures were comparable, but RAHM may be advantageous in difficult anatomical conditions or complex cases.

3. Systematic Review and Meta-Analysis

Ataya et al. (2023) analyzed several clinical studies and found that RAHM was associated with fewer intraoperative complications. Although the OR time was longer with RAHM, it offered ergonomic advantages for the surgeon and higher precision. There were no significant differences between the methods in terms of improvement in dysphagia symptoms.

4. Case-Control Study Directly Comparing RAHM and LHM

Sánchez et al. (2012) compared RAHM and LHM in a case-control study. They found that both procedures were equally effective in terms of symptom reduction. The robotic-assisted method was associated with lower intraoperative blood losses, while LHM had shorter OR times. The authors concluded that RAHM could be particularly advantageous in complex cases.

5. Meta-Analysis with 12,962 Patients on the Incidence of Esophageal Perforations

A meta-analysis by Tang et al. (2021) examined 14 observational studies with a total of 12,962 patients, of whom 2,503 received RAHM. The results showed that the incidence of esophageal perforations with RAHM was only 1.67 %, while it was 2.07 % with LHM. The risk of esophageal perforation was significantly reduced in the RAHM group (risk ratio: 0.31; 95% confidence interval: 0.16–0.59). There were no significant differences between the two procedures in terms of dysphagia and postoperative complaints.

6. Meta-Analysis from the International Journal of Medical Robotics

Chen et al. (2022) analyzed several studies and concluded that RAHM and LHM are comparable in terms of OR time, blood loss, hospital stay, and long-term outcomes. However, RAHM showed a significantly lower rate of intraoperative esophageal perforations (odds ratio: 0.13; 95% confidence interval: 0.04–0.45), indicating a potentially higher safety of the robotic method.

Comparison of the Procedures

The results of several studies and meta-analyses show that both surgical methods are effective and safe. While LHM remains widespread due to shorter OR times and lower costs, RAHM offers advantages in terms of precision and a lower risk of intraoperative injuries.

Conclusion

The studies show that both RAHM and LHM are effective surgical techniques for the treatment of achalasia. The robotic-assisted method offers particular advantages in terms of precision and a lower risk of intraoperative complications, while the laparoscopic technique represents an established, cost-effective, and time-saving alternative.

Since both methods provide comparable long-term treatment outcomes, the choice of procedure should depend on individual patient factors, the surgeon's experience, and economic aspects. Further prospective randomized studies are required to definitively confirm the long-term advantages of the robotic-assisted method.