Robotic Heller Myotomy, Thyroid and Gallbladder Surgery

A robotic Heller myotomy treats achalasia by dividing the thickened muscle at the junction of the oesophagus and stomach, so that food can pass freely again. During the operation, the surgeon checks for any leak with an on-table endoscopy. The same robotic and laparoscopic approach now covers reflux surgery, scarless thyroidectomy through the armpit and areola, and difficult gallbladder and bile duct stone surgery.

The upper digestive tract and the neck are where minimally invasive surgery has displaced some of the largest incisions in general surgery. Dr. Rakesh Durkhure, who heads General, Minimally Invasive and Bariatric Surgery at Artemis Hospitals, Gurugram, presented four areas in which he now operates robotically or laparoscopically: the oesophagus, the thyroid and parathyroid glands, the gallbladder, and the common bile duct. Across all four, the same discipline recurs: confirm the anatomy before cutting, test the repair before leaving theatre, and record the operation so that the patient and the referring doctor can see exactly what was done.

Robotic Heller myotomy for achalasia

What achalasia is

The first oesophageal problem Dr. Durkhure described is obstruction at the junction of the oesophagus and stomach. Patients present with difficulty swallowing, recurrent regurgitation and vomiting, because the gastro-oesophageal junction is tight and its muscle thickened. This is the picture of achalasia, in which the lower oesophageal sphincter, the ring of muscle that acts as a valve between the oesophagus and the stomach, fails to relax with swallowing, a consequence of the loss of the inhibitory nerve cells in the oesophageal wall.

How the operation is done and checked

The operation is a cardiomyotomy, known as a Heller myotomy: the surgeon divides the muscle fibres of the lower oesophagus and upper stomach down to the lining, so the pressure is released and food passes freely. Dr. Durkhure performs it robotically and laparoscopically.

The risk in any myotomy is an unrecognised breach of the lining, which would leak after surgery. Dr. Durkhure's safeguard is fixed: during the operation itself he always performs an endoscopic examination of the upper digestive tract, with a camera on a flexible tube, as far as the scope can reach, and checks the passage of fluid, so that any leak is identified on the table rather than after surgery.

Robotic fundoplication for acid reflux

Fundoplication treats the opposite problem: a valve that is too loose. Patients present with hyperacidity, gastro-oesophageal reflux disease (GERD), and regurgitation of food. The treatment Dr. Durkhure demonstrated on video is a robotic fundoplication, in which the upper stomach is wrapped around the lower oesophagus to reinforce the valve.

The steps he narrated show why the robot suits this operation:

1. Display the anatomy. He first shows the two limbs of the crus of the diaphragm (the muscular band that encircles the opening through which the oesophagus passes), the oesophagus between them, the liver above, and the posterior and anterior vagus nerves. He makes a point of displaying the anatomy during surgery, and the vagus nerves deserve it: preserving them protects normal emptying of the stomach afterwards.
2. Repair the crus. He closes the widened hiatus, the opening in the diaphragm.
3. Position the wrap. He passes the upper stomach behind the oesophagus using the shoe-shine manoeuvre, the step that positions the wrap before it is sutured around the lower oesophagus.

The video ends on the completed wrap, with the spleen in view beside it.

The robotic advantage is in the suturing. Working in the confined space behind the oesophagus, the wristed instrument can place and tie each stitch at angles that a straight laparoscopic needle holder struggles to achieve.

Replacing an injured oesophagus with the stomach

The most complex oesophageal case Dr. Durkhure presented was his youngest patient, whose oesophagus had been injured. He replaced the damaged oesophagus with the stomach, an operation in which the stomach is mobilised and drawn up to take the oesophagus's place as the conduit for food. The patient is now eating happily. The case shows how far advanced GI surgery reaches beyond the routine: the conduit for every meal a patient will eat can be rebuilt from the patient's own stomach.

Scarless thyroidectomy through the armpit and areola

A scarless, or remote-access, thyroidectomy removes the thyroid through small incisions in the armpit and the areola rather than across the front of the neck. Conventional thyroidectomy uses a transverse incision across the neck, from one side to the other, and for some patients, particularly women, the resulting scar is cosmetically unwelcome.

Working robotically or laparoscopically, Dr. Durkhure enters through the armpit and the areola, creates a working space beneath the skin, and tunnels up to the neck, in his words burrowing like a mouse. The thyroidectomy is then performed entirely within that tunnel, leaving no scar on the neck. He uses the same route for neck lymph node dissection and for parathyroid adenomas, benign growths of the small glands that regulate calcium. The benefits he reported are faster recovery and an excellent cosmetic result. Hospital costs for the operation are set out on the thyroidectomy cost page.

Robotic vs open thyroidectomy: complications and the 6 cm limit

In the live discussion, a doctor from Ethiopia asked how the complications of robotic thyroidectomy compare with those of open surgery. Dr. Durkhure began with an analogy. A Formula One driver put on a small city road will crash; a city driver put on a Formula One track will not know how to drive it. A particular set of operations needs a surgeon trained for that set. He has trained for it and has performed robotic thyroid and neck surgery for years.

His central point is that complication rates follow indication. If the indication is right, complications are fewer. His threshold is size: a thyroid nodule or lobe of no more than 6 centimetres is suitable for the robotic or laparoscopic route. Above 6 centimetres, he advises open surgery regardless of cosmetic considerations.

Technique is the second safeguard. Before removing the thyroid, he identifies the recurrent laryngeal nerve, which controls the vocal cords, on both sides, and all four parathyroid glands. These are the structures on which the two characteristic complications of thyroid surgery depend: voice change from nerve injury, and low calcium from parathyroid damage. In his view, avoiding them depends on meticulous dissection, whichever route is used: open, robotic or laparoscopic.

The carbon dioxide risk specific to remote access

He was candid about the risk specific to the remote-access route. In the hands of a surgeon not well versed in robotic surgery, operating time lengthens, and the longer the operation, the more carbon dioxide is absorbed through the subcutaneous tissue used as the working space. The result is a rise in the patient's end-tidal carbon dioxide, the level of carbon dioxide in the breath the patient exhales, during surgery.

ICG cholecystectomy: making difficult gallbladder anatomy visible

ICG-guided cholecystectomy uses a fluorescent dye to show the bile ducts during gallbladder removal, so the surgeon can tell the ducts apart before clipping anything. Gallbladder removal is the most common operation in general surgery, and Dr. Durkhure deliberately showed a difficult one rather than an easy one. The gallbladder is attached to the body by two structures, the cystic duct and the cystic artery, and the classic serious error of cholecystectomy is to mistake the common bile duct, the main channel carrying bile from the liver to the intestine, for the cystic duct.

His answer for complicated and atypical cases is indocyanine green (ICG). Once the dye is in the biliary system, the ducts fluoresce green under the camera, so the larger common bile duct and the smaller cystic duct can be distinguished before anything is clipped. The liver also glows green. When there is confusion about the anatomy, he said, ICG clears it up.

He showed the technique on both platforms: an ICG-guided robotic cholecystectomy followed by an ICG-guided laparoscopic cholecystectomy, so the difference in image quality between robot and laparoscope was visible. He uses plastic clips rather than metal clips. The recorded video of the operation goes to the patient. Hospital costs are listed on the gallbladder removal cost page.

Laparoscopic common bile duct exploration for stones

Stones throughout the bile ducts can be cleared entirely laparoscopically, without converting to open surgery. The final case in this section was a woman whose bile ducts were packed with stones: stones in the right hepatic duct, the left hepatic duct, and many more in the common bile duct itself. In Dr. Durkhure's phrase, she was hiding rocks in her tummy.

He cleared the duct entirely through keyholes. The key instrument is the choledochoscope, a fine scope that he passes into the opened bile duct and steers into each individual hepatic duct, removing stones under direct vision from each branch. The video showed stones still emerging from the left duct late in the procedure. Once the duct is clear, with a stent (a small tube that holds the duct open) in place, he closes it.

The recovery is the point of doing this through keyholes. Dr. Durkhure's patients begin eating and drinking normally three to four hours after surgery.

What the four operations have in common

Across the oesophagus, the neck and the biliary tree, the method is the same:

• Show the anatomy on screen before dividing anything: the vagus nerves, the recurrent laryngeal nerves, the parathyroid glands, the cystic and common ducts.
• Test the result before leaving theatre, with an on-table endoscopy or a direct look into each duct.
• Give the patient the footage.

For a referring doctor who will look after the patient for years afterwards, that record of what was found and done is as useful as the operation note itself. The same principles carry into his robotic hernia, colorectal and pelvic floor surgery, and his broader approach to the robot, consultation and implants is set out in the complete guide to robotic and laparoscopic surgery.