Robotic Anatomic and Physiologic Reconstruction of Paraesophageal Hiatal Hernias: Combining Lessons from a Century of Discovery and Controversy

A hiatal hernia is a common clinical entity which has been the subject of great controversy for over a century. During this time, medical practitioners have been like “blind” men who have examined the different parts of an elephant and reached a conclusion based on the partial knowledge but have been unable to recognize the “whole elephant.” The robotic approach to the repair of hiatal hernias which not only incorporates the technology of robotics but is also designed to return the anatomy and physiology of the hiatus to its normal function is the culmination of the work of many surgical giants who independently identified specific parts of the “elephant” that is represented by the entity of a hiatal hernia. In addition, in the past 50 years, two significant realizations have changed the understanding of hiatal hernias. First, hiatal hernias are now seen as a pathologic process that is more than GERD (gastroesophageal reflux disease). Second, a hiatal hernia is identified as a common condition which by virtue of its anatomic location affects more than the gastrointestinal system. This chapter outlines the history of the surgical treatment of hiatal hernias, identifies the modern understanding of the anatomic and physiologic aspects of the esophageal hiatus and the gastroesophageal antireflux mechanism, proposes a clinically more relevant classification of hiatal hernias based on symptoms rather than anatomy, outlines the indications for surgical repair, and finally provides a step-by-step approach to the robotic anatomic and physiologic repair of hiatal hernias.