Robotic Paraesophageal Hernia Repair

Paraesophageal hernias are an uncommon form of hiatal hernia (10%). Symptomatic hernias should be repaired unless there are clinical parameters precluding safe and effective surgical intervention. Robotic repair is an efficient and ergonomic approach to this challenging anatomical problem. The preoperative evaluation consist of a careful documented medical history and a workup comprising a esophagogastroduodenoscopy, pH testing (only performed if patients had disabling reflux symptoms), upper GI series and high-resolution manometry. OR size must accommodate the robotic system consisting of three to four integrated components; the patient cart, the vision cart, and one or two consoles. The patient is placed in supine position with outstretched arms to 80° and split legs in steep reverse Trendelenburg. Four trocars, placed in the left upper abdomen and a subxiphoid incision for the Nathanson liver retractor are employed. The patient cart is docked on the left side or the head depending on the robot model. The herniated contents are reduced, the hiatus and the left crus are exposed, the hernia sac is dissected off its mediastinal attachments, and any violation of the pleura should be addressed by means of immediate closure with suture or clip placement. A 3 cm intra-abdominal esophageal length should be obtained with esophageal mobilization alone, otherwise a Collis gastroplasty must be performed to obtain additional esophageal length. The crura is closed using a running 0 non-absorbable barbed suture and a C-shaped GORE® Bio-A mesh is used routinely to reinforce the closure. A tension-free 360° fundoplication is gauged over the bougie. The shoeshine maneuver is fundamental to ensure the proper orientation of the wrap demonstrating a “short-gastric to short-gastric” association. It is important to recognize common early complications like; violation of the pleura and pneumothorax, bleeding, vagal injury, esophageal and gastric perforation and late complications like dysphagia, severe reflux and recurrence. Operation of a symptomatic recurrent paraesophageal hernia should be performed by highly experienced surgeons, as these procedures represent a substantial technical challenge. In this setting, the robotic platform presents an invaluable approach. The best timing for operative repair after an acute presentation is a subject of ongoing debate. Although any clinical or radiological suspicion of acute ischemia or perforation requires immediate surgical management, most acute presentations can be initially managed conservatively providing the opportunity for semi-elective repair. Robotic compared to laparoscopic Nissen fundoplication and hiatal hernia repair has been demonstrated to be associated with increased costs in several studies.