615. ROBOTIC REDO LAPAROSCOPIC HELLER’S CARDIOMYOTOMY

Abstract Introduction Robotic Heller’s cardiomyotomy is the preferred treatment option for achalasia cardia. However, following Heller’s cardiomyotomy up to 20% of patients experience dysphagia and regurgitation in the long term. The ideal management option for such patients needs to be determined. Surgical Steps The procedure is carried out with patient in supine position, legs abducted with the knees in slightly flexed position in reverse Trendelenburg position of approximately 30°.The pneumoperitoneum is created by closed Veress needle technique. After Relasing Adhesions, the gastrohepatic ligament is divided and the right crus is identified and retrocardiac window is formed; proximal short gastric vessels are divided for posterior wrap. The esophagus is separated by blunt dissection from the crus, the peritoneum and phrenoesophageal membrane are divided and the left crus is identified. If an anterior partial fundoplication is planned as antireflux procedure, the mobilization is limited to the lateral and anterior aspects. The anterior vagus nerve is identified and should be dissected and lifted away from the distal esophagus and proximal stomach in order to facilitate transhiatal dissection, myotomy and also to prevent injury to the esophagus and vagal trunks. Dissection is continued cranially around the esophagus for a distance of about 2–3 cm onto the dilated segment of the esophagus in the posterior mediastinum. If posterior partial wrap (Toupet) is planned, esophagogastric dissection is performed posteriorly from both crura and median arcuate ligament to get tension free wrap. Fundus of the stomach is dissected off the diaphragm and if needed two or three short gastric vessels are divided. Posterior vagal trunk is dissected along with esophagus. Conclusion Redo Robotic Heller’s cardiomyotomy can safely be performed with good symptomatic relief for patients who present with recurrent symptoms following Heller’s cardiomyotomy. Long term follow-up with larger sample size is needed to confirm these findings. https://drive.google.com/file/d/1uFgx0Aal92o5FE-Ndp-tAsCg01NJ6Crm/view?usp=sharing