Our standard approach is always trans-abdominal [31, 32]. This can be performed as a combination of laparoscopic technique with robotic assistance or a purely robot-assisted approach. In our practice, the initial approach to the dissection is laparoscopic, but the actual myotomy is performed with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA). The da Vinci System provides a magnified stereoscopic image to the surgeon seated at a console away from the patient, which we find to be very useful in establishing the plane of dissection beneath the muscular layer and avoiding iatrogenic mucosal perforation. The da Vinci System provides six degrees of movement with a wristed action that allows delicate sweeping movements to create this plane. It also dampens any tremors and can be scaled to allow very fine movements by the surgeon as the muscle is elevated and divided.

All patients undergo standard pre-operative evaluation for general anesthesia and laparoscopy. They are placed on a clear liquid diet for 3 days to decrease the amount of retained food in the esophagus. They are given a clear liquid protein supplement during this time. A type and screen for blood is not routinely obtained. All patients are given pre-operative intravenous antibiotics within an hour of incision. Mechanical and chemical prophylaxes are given for venous thromboembolism prevention. Patients are placed supine on the operating table with a foot board in place to allow steep reverse Trendelenburg positioning without shifting. A Foley catheter and an orogastric tube are placed. The arms are tucked at the sides, and the lower legs and shoulders are padded. A thigh strap is placed, and the lower legs and shoulders are taped to the operating table. The overhead monitor is placed over the patient’s head to allow the operating surgeon and assistant to look at the same screen. Our practice is to set the room up so that the robot may be docked from the head of the bed, with the anesthesia equipment to one side and the surgical equipment to the other side, as shown in Fig. 4.3.

Access to the abdomen is gained with a Veress needle to create pneumoperitoneum, and an optical 12 mm trocar is placed. This camera port is not placed in the midline, but rather in line with the diaphragmatic hiatus, to facilitate triangulation around the hiatus. This is about 3 cm to the patient’s left of the umbilicus, 15 cm inferior to the xiphoid process. Two 8 mm ports are placed along the left costal margin, as close to the rib as possible. The lateral left costal margin port is placed as far lateral as possible to prevent collision of the robot arms. A Nathanson liver retractor is placed inferior to the xiphoid process to elevate the left lobe of the liver to visualize the hiatus, and it is fixed to a post on the operating table. An 8 mm port is placed to the patient’s right of the epigastrium, and the trocar is advanced through the falciform ligament, which prevents the falciform ligament from hanging in front of the instrument being advanced into the abdomen (Fig. 4.4). The patient is then placed in steep reverse Trendelenburg position, with the patient’s right side tilted down. The robot is docked at this time. The operating assistant stands on the patient’s left side and provides lateral retraction of the fundus of the stomach. Alternatively, this could be performed by the third working arm of the robot. The surgeon begins with an atraumatic grasping device in the left hand and a monopolar cautery hook in the right hand. This is used to divide the phrenoesophageal ligament to expose the angle of His. The left pillar of the crus must be visualized, and dissection is carried anteriorly toward the midline. The lesser sac is then entered through the lesser omentum, and the right pillar of the crus is identified. This dissection is carried anteriorly up to the level of the contralateral side. The anterior vagus nerve is adherent to the esophagus and must be identified and mobilized to allow for a complete myotomy. The anterior vagus lies on the esophagus at the 1 o’clock position and crosses toward the lesser curvature (Fig. 4.5). It has attachments on the medial and lateral side that must be divided separately to fully mobilize it. Limited use of thermal energy is important to prevent nerve damage. The phrenoesophageal ligament and esophageal fat pad are divided in the midline to expose the muscular layers at the GE junction, taking care to note the position of the vagus nerve as it passes through this fat pad.

The fundus of the stomach may require some mobilization to allow for the partial fundoplication, particularly in the obese male patient. The short gastric vessels should be divided with an energy device (the authors prefer a bipolar sealing/cutting device) along the greater curvature of the stomach. This typically requires division of the first short gastric vessels. A posterior dissection and identification of the posterior vagus nerve are not necessary and should be avoided in order to maintain the native anatomy of the hiatus. The esophagus is exposed at least 8 cm above the GE junction. The esophagus is then lightly scored with a monopolar hook cautery to demarcate the site of the myotomy, with a goal of a 7 cm esophagomyotomy and a 3 cm gastromyotomy, including the sling fibers at the GE junction.