Robotic Heller myotomy and modified Dor fundoplication.

A 67-year-old female presented with progressive dysphagia to solids and liquids. Imaging was concerning for end-stage achalasia with multiple failed attempts at pneumatic dilation. An outside hospital recommended oesophagectomy, but she came to our clinic for a second opinion. Computed tomography revealed tortuous megaoesophagus measuring up to 7 cm. Barium swallow revealed aperistalsis. Oesophageal manometry revealed an elevated integrated relaxation pressure, 100% failed peristalsis and panoesophageal pressurization in >20% of swallows, consistent with type II achalasia. We recommended a robotic Heller myotomy and Dor fundoplication. The patient was positioned supine with four 8 mm ports across the mid-abdomen. The pars flaccida was opened to access the right crus and oesophageal hiatus. The phreno-oesophageal ligament was taken down and the dissection was carried cephalad into the mediastinum. The greater sac was opened and the short gastric vessels and gastrosplenic ligament were taken down. The gastro-oesophageal junction fat pad was resected. A myotomy was created using a robotic hook without energy extending 6 cm on the oesophagus and 2 cm over the stomach. Modified Dor fundoplication was completed using four interrupted sutures. The patient was given a soft diet and discharged on post-operative Day 1. She subsequently had complete resolution of her dysphagia.