Robotic Heller Myotomy for Achalasia: A Narrative Review of the State-of-the-Art Technique and Its Future Directions

Achalasia is a rare motility disorder causing impaired lower esophageal sphincter relaxation and absent peristalsis. Surgical myotomy remains key; robotic-assisted Heller myotomy (RAHM) is increasingly used alongside laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). Evidence indicates RAHM yields outcomes similar to LHM with fewer mucosal perforations, likely due to improved visualization and dexterity. POEM offers shorter operations and longer, tailored myotomies, especially for type III but higher postoperative reflux without antireflux measures; fundoplication is standard after surgical myotomy. Long-term control is durable across approaches; cohorts suggest RAHM advantages in barium emptying, reintervention, and Eckardt scores. RAHM costs more than LHM, while POEM can be cost-efficient. Innovations may enhance clinical precision. Selection should consider anatomy, reflux risk, prior therapy, and expertise. In this review, we aimed to synthesize evidence on robotic Heller myotomy (RHM) for achalasia, comparing indications, long-term outcomes versus LHM and POEM, appraising reflux management and costs, and outlining learning curves, limitations, and future research priorities.