Enhancing peritoneal visualization in paroral endoscopic myotomy with fund duplication using novel robotic peritoneal pressure optimization. Paroral endoscopic myotomy, or POEM, has been established as an effective procedure for the treatment of akalasia. Adding endoscopic fund duplication following POEM is a mechanism that helps relieve patients from post-operative gastroesophageal reflux disease symptoms, which can arise as a complication after POEM. During fund duplication, generating capnopritonium is necessary to optimize the visualization of structures inside the peritoneal. In summary, in POEM, the submucosal injection is performed and a mucosal bleph is created. Then, a 2.5 centimeter mucosal incision is made using electrocutory knife. This is followed by dissection of submucosal fibers and creating submucosal tunneling. Finally, esophageal and gastric myotomy is performed. In fund duplication, the perigastric fat and serosa overlaying the gastric myotomy is dissected and opened to gain entry into the peritoneal cavity. The fundus is grasped and retracted into the tunnel to simulate the wrap. The wrap is viewed from within the gastric lumen using an ultra-slim scope parallel to the gastroscope. When the wrap simulation deems satisfactory, the corresponding position of fundic serosa is marked. The endo-loop device is grasped by an endoscopic clip and fixed distally to gastric fundus. The proximal end of the endo-loop is fixed to the distal end of the myotomy on the peritoneal side. Then, the endo-loop is gradually tightened. After loop deployment, the loop tail is trimmed. Finally, the mucosal incision is closed using endoscopic clips. Peak airway and intraperitoneal pressures need to be regulated throughout the fund duplication procedure. The goal is to maintain a low but stable intra-abdominal pressure. This is necessary to prevent cardiopulmonary complications and concurrently optimize the visualization of structures inside the peritoneum. In needle decompression technique, a peritoneal decompression needle is inserted through the anterior abdominal wall to manage the level of capnoperitoneum generated by insufflating CO2 through the gastroscope. It is necessary to comprehensively inspect the peritoneal cavity to verify the absence of unintended vascular or visceral The needle decompression technique has certain challenges. When utilizing this technique, intra-abdominal pressure may fluctuate. In fund duplication procedure, where direct measurement of intra-abdominal pressure is challenging, close attention is placed on the continuous monitoring and optimization of peak inspiratory pressure to prevent potential complications. Robotic insufflator is a pressure control system that precisely administers and maintains the targeted pressure within the peritoneum. This system measures the pressure in the CO2 delivery tube and it automatically regulates intra-cavity pressure by insufflating additional flow for active evacuation in response to pressure fluctuations. The potential benefits of robotic laparoscopic insufflator is consistent pressure. It eliminates the need for frequent decompression needle adjustments as intra-abdominal pressure fluctuates. This technique allows pressure settings to remain constant for procedural stability. In our case, initially, we used the robotic insufflator through the scope, yet this method was unsuitable due to the flow limitation imposed by the scope channel, which restricted insufflation within a space as large as the peritoneal cavity. Consequently, we transitioned to using a peritoneal decompression needle, which has far less flow restriction. This needle was used in conjunction with the robotic laparoscopic insufflator connected through the anterior abdominal wall. This approach provided consistent pressure maintenance during the fundoplication procedure. In this video, the insertion of peritoneal decompression needle through the anterior abdominal wall is demonstrated. Connecting the robotic insufflator to the needle was associated with the stability of intra-abdominal and peak airway pressures, eliminating the need for continuous monitoring and adjustment. When tightening the endo-loop for wrap formation in fundoplication, the robotic insufflator could be used to quickly decrease intra-abdominal pressure, collapsing the peritoneal cavity and creating a tight wrap. The robotic insufflator connected to a peritoneal decompression needle through the abdominal wall provided a reliable method for maintaining a stable and constant intra-abdominal pressure throughout the fundoplication procedure. The insufflation pressure of 12-14 mmHg was demonstrated to be optimal. Peak airway pressure was maintained stable around 20-21 cmH2O. Moreover, the deflation was quicker because active evacuation was implemented by the robotic insufflator. One crucial benefit of a robotic insufflator is its enhancement of procedural safety. A significant concern during CO2 insufflation is tensioned capnoperitoneum, which can compromise cardiovascular and respiratory functions. Maintaining intra-abdominal pressure stability at the targeted pressure effectively prevents this issue. In conclusion, the advantages of robotic insufflator in POEM-F include enhanced visibility, consistent intra-abdominal pressure, and its automated monitoring and adjustment, reduced need for manual decompression needle intervention and respiratory parameters adjustment, and decreased risk of tensioned capnoperitoneum. Furthermore, besides its application in POEM-F, the use of robotic insufflators extends to other advanced endoscopic procedures like full thickness resection and natural orifice transluminal endoscopic surgery.

peritoneal visualization

paroral endoscopic myotomy

fund duplication

robotic peritoneal pressure optimization

gastroesophageal reflux disease