In this study, which provides a comparative analysis of RAHM versus LHM using the large prospectively collected NSQIP dataset, RAHM demonstrated equivalent mortality, reoperation and readmission rates as well as a similar length of hospital stay compared to LHM; however, RAHM was associated with higher overall morbidity and a longer average operative time.

Minimally invasive Heller myotomy has long been established as the preferred surgical approach for achalasia, with robust evidence supporting its safety and efficacy in achieving long-term dysphagia relief [3]. Our study aligns with existing literature demonstrating equivalent 30-day mortality between RAHM and LHM, consistent with prior cohort analyses and meta-analyses [3,4,5,6]. However, we observed a statistically significant increase in overall morbidity in the RAHM cohort, driven primarily by elevated rates of deep venous thrombosis (DVT), myocardial infarction (MI), and soft tissue infection (SSI), both in aggregate and matched analyses. This finding contrasts with prior large-scale studies, such as Chacko et al. in 2022, which reported improved morbidity in the robotic cohort, although notably, their analysis did not assess DVT or soft tissue infection rates, which may partially account for the discrepancy [6]. Conversely, the meta-analyses by Ataya et al. and Shaligram et al. reported no significant differences in morbidity or mortality but lacked detailed evaluation of individual postoperative complications [3, 4]. These comparisons highlight the importance of granular outcome analyses to uncover specific risks that may not be apparent in broader composite morbidity metrics.

A key strength of our study is that it is the first to utilize the NSQIP database following its 2022 update separating robotic procedures, providing a broad prospective national sample to examine postoperative complications. The divergence in morbidity we observed, particularly the trends toward significance in DVT, MI, and SSI within the matched cohorts, is notable, especially given the equivalence in baseline co-morbidities. These findings suggest that factors beyond patient characteristics, such as perioperative management and procedural nuances, may contribute meaningfully to complication rates and deserve further investigation. Among these potential contributors to increased morbidity, prolonged operative time emerges as a critical and potentially modifiable factor. With similar patient preoperative risk factors, the significantly longer operative duration in RAHM becomes a key differentiator. Prior NSQIP analyses, such as Sakran et al., have shown that surgeries exceeding 100 min increase venous thromboembolism (VTE) risk, with every additional 10 min elevating DVT risk by 7% [7]. While these associations are compelling, it is important to recognize that correlation does not imply causation, and we cannot exclude confounding factors such as surgical complexity or institutional protocols. Moreover, although measures such as preoperative chemical prophylaxis (e.g., heparin or enoxaparin) and intraoperative sequential compression devices (SCDs) are standard tools to mitigate VTE risk, the NSQIP dataset unfortunately does not track adherence to these prophylactic strategies, limiting our ability to assess whether compliance differed between RAHM and LHM cohorts [8, 9]. Additionally, the established correlation between prolonged operative time and increased SSI rates, as shown by Cheng et al., further reinforces the need to address operative efficiency in robotic surgery as a modifiable risk factor [10, 11].

The significant increase in operative time for RAHM, averaging 42 min longer than LHM, could partially explain the morbidity differences observed. Notably, this time difference exceeds the 23 min gap reported by Ataya et al. [4]. However, when compared to Milone et al., which found no statistically significant difference between platforms, or to Raja et al., a single-institutional high-volume center reporting a 21 min decrease in RAHM time, the discrepancies become striking [12, 13]. These variations suggest that operative efficiency may be highly dependent on institutional experience, surgical training, and robotic familiarity of the hospital staff.

A frequently cited advantage of RAHM is its potential to reduce intraoperative esophageal perforation, a complication with significant clinical consequences. While our dataset did not collect intraoperative data, we observed equivalent deep organ soft tissue infection rates, length of stay, readmission rate, and reoperation rates between RAHM and LHM. Previous studies have reported conflicting results regarding perforation risk. Chacko et al. found a statistically higher perforation rate, with RAHM using 2010–2015 data, whereas Ataya et al. and Aiolfi et al., reported a significantly lower perforation risk with robotic assistance, though both included Chacko et al.’s data in their analyses [4,5,6]. Our data suggest that, at minimum, perforation rates with RAHM are comparable to LHM, with minimal long-term complications, reinforcing the safety profile of the robotic approach.

There are several limitations in this study including NSQIP’s lack of granular data on preoperative factors (number or preoperative interventions, type of achalasia, manometry), or intraoperative complications (e.g., esophageal perforations, reoperative cases). Moreover, it does not capture functional outcomes (e.g., Eckardt scores, long-term dysphagia relief), or surgeon-level experience or institutional case volume which are central to evaluating the success of achalasia interventions. Finally, although we observed differences in operative time and morbidity, these may reflect unmeasured confounders, including institutional or surgeon-level variability, and the relatively small number of robotic cases raises the possibility of sampling bias.