How Is A Hiatal Hernia Repaired Using Robotics
JSLS. 2022 Jan-Mar; 24(1): e2019.00054.
Robotic Fundoplication for Large Paraesophageal Hiatal Hernias
Massimo Arcerito, Md, FACS, 
Martin Thou. Perez, MD, Harpreet Kaur, Physician, MBBS, Kenneth M. Annoreno, CST, and John T. Moon, MD, PhD, FACS
Massimo Arcerito
Riverside Medical Dispensary Inc., University of California Riverside Schoolhouse of Medicine, Riverside, California.
Sectionalization of Full general and Vascular Surgery, Riverside Community Infirmary, Riverside, California.
Riverside Community Hospital, Riverside, California and Division of General and Vascular Surgery, Rancho Spring Medical Centre, Murrieta Temescal Valley California.
Martin G. Perez
Riverside Medical Dispensary Inc., University of California Riverside School of Medicine, Riverside, California.
Partition of General and Vascular Surgery, Riverside Customs Hospital, Riverside, California.
Harpreet Kaur
Division of Full general and Vascular Surgery, Riverside Community Infirmary, Riverside, California.
Kenneth M. Annoreno
Sectionalisation of General and Vascular Surgery, Riverside Community Infirmary, Riverside, California.
John T. Moon
Shawnee Mission Medical Heart, Shawnee Mission, Kansas.
Abstruse
Purpose:
Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux illness (GERD) with sliding hernia. The all-time outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel arroyo in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique.
Methods:
Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. L-8 patients underwent total fundoplication, eleven patients had fractional fundoplication, and i patient had a Collis-Nissen fundoplication for caused short esophagus.
Results:
All procedures were completed robotically, without laparoscopic or open conversion. Hateful operative fourth dimension was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (vii–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically.
Conclusions:
The success of robotic fundoplication depends on adhering to a few important technical principles. In our feel, the robotic surgical treatment of gastroesophageal reflux illness with large paraesophageal hernias may afford the surgeon increased dexterity and is viable with comparable outcomes compared with traditional laparoscopic approaches.
Keywords: gastroesophageal reflux disease, robotic full fundoplication, robotic partial fundoplication, paraesophageal hiatal hernia, biological absorbable mesh
INTRODUCTION
At that place has been significant improvements in laparoscopic surgery since its inception in the early on 1990s.i Today about whatsoever traditionally open surgery in the abdomen or chest tin can be performed using minimally invasive principles with equivalent or ameliorate outcomes. Laparoscopic full fundoplication has been proven to be efficacious, providing sustainable relief in treating severe gastroesophageal reflux disease (GERD) and reducing small and big hiatal hernias.2 The indication for surgical treatment of GERD is accepted for patients who respond to medical treatment, rather than treating those who are unresponsive.iii In our exercise, nosotros prefer to select clinical responders with sliding hiatal hernia to perform a total versus partial fundoplication based on the results of esophageal function tests.4 The presence of a large paraesophageal hiatal hernia, classified as a herniation of 30% of the stomach into the chest, represents most patients in our practice. This anatomical and physiologic aberration is an indication for intervention alone, contained of a patient'south response to medications. A recent meta-analysis showed that partial compared with total fundoplication is more successful in the handling of GERD with less postoperative dysphagia.v Conversely, total fundoplication is more efficacious in controlling GERD symptomatology, compared with partial fundoplication, regardless of the harm of esophageal move detected by the preoperative esophageal part tests.2 Nosotros align with the latter theory, focusing our efforts in creating a more durable result with a total fundoplication. Nosotros limited partial wraps to patients with primary motion disorders like scleroderma or esophageal achalasia, and, more recently, elderly patients with large paraesophageal hiatal hernia in whom preoperative esophageal function tests are not performed. To avoid postoperative dysphagia, the total fundoplication is performed over a bougie dilator of different sizes, tailoring the surgical treatment for each patient, individually.
Whereas there has been significant improvements in laparoscopic instruments over the years, they are withal limited in their ability to perform surgery in tight spaces or challenging angles. Those limitations make traditional minimally invasive antireflux surgery challenging, peculiarly in the treatment of large paraesophageal hiatal hernias. The recent introduction of robotic surgery reduces those limitations by granting the user increased dexterity of movements with the advent of wristed instruments.
MATERIALS AND METHODS
This prospective report was authorized by the Inquiry Oversight Committee at Riverside Community Hospital under Hospital Corporation of America with file number RCH-42.
Betwixt March 2022 and June 2022, 110 patients (37 males and 73 females), mean age of 63 y sometime, (22–92) with diagnoses of GERD and hiatal hernia, were treated with robotic fundoplication. Of those, 25 patients were classified as GERD and type I sliding hiatal hernia, while 15 patients underwent robotic REDO fundoplication for failure of previous laparoscopic antireflux surgery. The remaining 70 patient (23 males and 47 females), hateful age 64 y old, (22–92) were diagnosed with large paraesophageal hiatal hernia with more than 30% of tummy herniated into the chest.half-dozen Twelve patients with noncardiac chest pain were referred to us. Preoperatively, heartburn was present in 25 patients, cough in 49 patients, regurgitation in 63 patients, and dysphagia for both solids and liquids in 56 patients. In improver, seven patients were referred with atrial fibrillation that the cardiologists who believed the symptomatology was secondary to their large paraesophageal hiatal hernia. All patients were scheduled to undergo robotic fundoplication. All patients underwent preoperative esophagogastroduodenoscopy and upper gastrointestinal serial (UGI) ( Figure 1 ). 30-six patients underwent esophageal manometry and 24-h pH monitoring studies. Computerized tomography scan of chest was obtained in twenty patients ( Figure 2 ). Eleven patients presented at emergency department with obstructive symptoms secondary to an centric rotation and gastric volvulus in viii patients and Cameron ulcer in three patients. We routinely used biosynthetic mesh for reinforcement of the diaphragmatic crura (GORE BIO-A, Flagstaff, AZ). Biosynthetic mesh reinforcement was utilized in 63 patients. Early in the feel, seven patients (10%) did not accept mesh placement subsequently endmost the hiatus. Nosotros describe the operative technique in detail, emphasizing all the important technical elements.
Upper GI series showing a large type III paraesophageal hiatal hernia.
Computed tomography browse of the chest showing a large type III paraesophageal hiatal hernia.
Operative technique
Patient training.
After induction of general endotracheal anesthesia, the patient is placed in steep reverse Trendelenburg. A foley is utilized. The Da Vinci Robot (Intuitive Surgical Inc., Sunnyvale, CA) is docked above the head (Si model) or at left hip expanse (Xi model). A nasogastric tube is placed to assistance to decompress the stomach during surgery. A bougie dilator (l to 54 French) is placed in the centre third of the esophagus, pending advocacy into the breadbasket at the time of the fundoplication technique. The nasogastric tube is removed postoperatively.
Laparoscopic access
Initially, with the patient in supine position, a v-mm Optiview trocar (Applied Medical Inc., Rancho Santa Margarita, CA) is placed in the right upper quadrant with a 0-caste scope. Pneumoperitoneum is set at 14 mm Hg. A 150-mm-long, 12-mm balloon trocar (Si model) or the new 8-mm trocar (Eleven model) is placed 13 cm inferior from the xiphoid process for the robotic photographic camera (30 degrees), an 8-mm robotic trocar in the left upper quadrant, and a 12-mm balloon trocar in the left lower quadrant for laparoscopic assist. The initial five-mm port is then upsized to an 8-mm robotic trocar. A laparoscopic Nathanson retractor (Mediflex Surgical Products, Islandia, NY) is introduced in the epigastrium to lift the left lateral segment of the liver to provide excellent exposure to the hiatus. The Nathanson is anchored to a flexible laparoscopic holder (Thompson Surgical Instruments, Traverse, MI) and a post along the patient's correct side. An additional 5-mm assist port is placed in the right lower quadrant. Figure three shows our ideal port placement. Of note, it is important to maintain at least 12 cm altitude betwixt the robotic trocars and the robotic camera port to avoid robotic arm collisions during the surgery.
Robotic accesses for the robotic fundoplication. A: Liver retractor. B and D: Robotic arms. C: Robotic camera. Due east and F: Assistant ports (the pentagon scheme).
Robotic equipment
Our preferred robotic equipment for the process includes an Ultrasonic device, a bipolar grasper, a Cadiere grasper, a Suture Cut needle commuter and, intermittently, the monopolar hook device for fine autopsy. The functioning is continued robotically after docking the robot to the patient.
Steps of the performance
Pace one: division of the gastrohepatic ligament, isolation of the correct crus, and identification of the posterior vagus nerve.
Figure 4 shows a typical robotic view of a large hiatal hernia. The operation is started by dividing the gastro-hepatic ligament while preserving the replaced left hepatic artery, when present. The ii initial robotic instruments are the bipolar grasper for arm 2 and an ultrasonic device for arm i. The camera is placed in thirty-degrees-down configuration. The ultrasonic device provides for rubber division of the tissue fugitive any collateral damage to the surrounding tissues based on its minimal lateral thermal spread of the ultrasonic waves. The ultrasonic device is utilized throughout the entire process. When present, the accessory left hepatic artery tin can be sacrificed if there is a need for further exposure. It is mandatory to recognize the posterior vagus nerve, once the big paraesophageal hiatal hernia is reduced into the abdomen, to avoid permanent damage and severe postoperative gastroparesis.eight In the presence of big hiatal hernias, it is preferable to divide the hernia sac at the level of the correct crus level once the crus is identified ( Figure v ). This maneuver allows successful dissection of the hernia sac and mobilization of the right portion of the hernia down to the abdomen without undue tension on the reduced breadbasket.
Robotic view of a large hiatal hernia.
The hernia sac is divided at the right crus level one time the crus is identified.
Stride two: mobilization of the phrenoesophageal membrane with mobilization of the left crus and recognition of the anterior vagus.
The phrenoesophageal membrane is divided. The dissection of the hernia sac at this level is continued toward the upper portion of the left crus. Again, this maneuver allows a successful dissection of the intrathoracic hernia sac at the stomach level, reducing the stomach into the abdomen. The upper portion of the left crus is then exposed. The anterior vagus nerve needs to be identified once the entire tummy is reduced into the belly to avert its damage. The dissection follows the length of the left crus, mobilizing the hernia sac away and further reducing the stomach down to the abdomen. At this point of the functioning, traction on the tum wall sometimes causes serosal tears or gastric perforation, which can exist easily repaired using intracorporeal stitches. In our experience, this event occurred twice with successful robotic repair, without a need for open conversion.
Step three: partition of the short-long gastric vessels in behemothic hiatal hernias.
We believe this step is of paramount benefit in mobilizing the stomach with great exposure of its posterior wall.9 This maneuver can be easily accomplished using the robotic ultrasonic device. The division of short gastric vessels provides the reduction of the greater curvature and the posterior wall of the stomach, exposing the pancreas. Effigy half dozen shows the division of the curt gastric vessels. There is almost e'er a posterior fat hernia sac backside the stomach that needs additional resection to avert possible postoperative recurrences of hiatal hernias. Going behind the posterior wall of the stomach, we isolate the left crus of the diaphragm, which joins the correct crus and, indirectly, creates the retroesophageal window, once the entire stomach is reduced into the belly. 1 of the possible complications is vehement the short gastric vessels during their mobilization. Careful use of the ultrasonic device dramatically reduces this consequence. The robot technique provides fantabulous exposure of the left upper quadrant during this stride of the surgery.
Division of the short gastric vessels.
Step 4: cosmos of the retroesophageal window and completion of the resection of the hernia sac.
The reduction of the posterior gastric wall from the breast to the belly allows united states to create a wide retroesophageal window. A Penrose bleed is placed to retract the distal esophagus. The inductive and posterior vagus nerves are always identified and protected. Information technology is advisable, after retracting the distal esophagus, to remove the fat pad at the gastroesophageal junction. In add-on, this maneuver helps to resect the final adhesions at the distal third of the esophagus, lengthening it enough to build the fundoplication in the abdomen without tension. The terminal attachments between the esophagus and the right and left crus are divided. Figure 7 shows the completion of the retroesophageal window and the open up diaphragmatic crus.
Completion of the retroesophageal window and the open up diaphragmatic crus.
Step 5: closure of the diaphragmatic crura and placement of absorbable mesh.
Usually in large hiatal hernias, it might be difficult to close the correct and left crus based on the chronicity of the disease and the distance between the diaphragmatic pilasters. In our experience, with only 1 exception, the diaphragm was closed successfully. This tension free closure might exist due to the thorough dissection of the hernia sac, laterally and posteriorly. The ultrasonic device is then substituted by the Da Vinci Mega Suture Cut Needle Driver. Iii stitches of 2–0 silk are placed. The first stitch is placed at the junction of the right and left crus. The distance between the remaining stitches is 1 cm and the final altitude between the well-nigh superior stitch and the posterior wall of the esophagus needs to be at to the lowest degree 1 cm. Effigy eight shows the completed closure of the diaphragmatic crura. A released cut to the left diaphragm was performed in one patient with subsequent successful closure of the crus. In all but vii patients with big hiatal hernias, a GORE Bio-A Tissue reinforcement is placed (Gore, Flagstaff, AZ). Made with absorbable fabric, this mesh degrades in vivo through hydrolysis and is fully absorbed within three–6 mo. The U-shaped mesh allows a tissue reinforcement over the closed crura without compromising the passage of the distal esophagus into the abdomen. Several stitches of 2–0 silk are placed to anchor the mesh around the right and left crus and backside the esophagus to avoid potential posterior gastric hernia recurrence. Figure ix shows the final position of the Bio-A mesh over the closed crura before performing the fundoplication.
Completed closure of the diaphragmatic crura.
Position of the BIo-A mesh over the airtight crura earlier performing the fundoplication.
Step 6: cosmos of fundoplication afterward insertion of a Bougie dilator.
Using the retroesophageal window, the posterior wall of the gastric fundus is pulled over to create the fundoplication. The ii edges of the breadbasket are maneuvered back and forth to notice tension and to ensure the right side of the fundus to stays in identify. The complete autopsy of the curt gastric vessels and the posterior wall of the tum determines the success of this step. Furthermore, the presence of the short gastric vessels in the correct portion of the fundoplication shows its absenteeism of tension, minimizing the take a chance for postoperative dysphagia and gas bloating in our patients.nine Nosotros and then ask our anesthesiologist to advance the bougie, previously placed in the middle third of the esophagus, into the gastric lumen, stopping with any sign of resistance. 1 of the most serious complications is bougie penetration of the esophageal wall. If this is the case, information technology is mandatory to convert the process and to appraise the damage at mucosa and muscle level and repair information technology. To avert any resistance, we always cut the suture holding the Penrose to allow a straight passage of the bougie from the distal esophagus to the breadbasket. Once the bougie is positioned, the fundoplication is created. We always favor the total fundoplication versus the partial one, limiting the latter to patients with preoperative diagnosis of severe esophageal motion disorders, like scleroderma or primary esophageal achalasia.two The fundoplication is about 3 cm in length. The start ii–0 silk sew together closes the ii flaps of the fundus without incorporating the esophageal wall. This maneuver allows us to move the fundoplication proximally above the gastroesophageal junction and so two more stitches are place about ane cm apart including both fundus flaps and the inductive wall of the esophagus. The bougie is then removed by the anesthesiologist. Three more stitches are placed to anchor the fundoplication into the belly. Specifically, two coronal stitches including the diaphragm, the esophagus, and the fundus at right and left upper corners are placed to annul the cephalic forces that might draw the fundoplication into the breast. An additional stitch is placed between the right fundus flap and the mesh/airtight crura to annul the twisting movement of the fundoplication dorsum to the left upper quadrant. Figure ten shows the completed total fundoplication. Afterwards completing the fundoplication, intraoperative upper endoscopy is performed to confirm the integrity of the fundoplication and absence of stricture at the gastroesophageal junction level.
Completed total fundoplication.
Step half-dozen bis—partial fundoplication.
In the presence of astringent impairment of esophageal peristalsis, we prefer the posterior partial fundoplication (240 to 270 degrees).ten The right fundic flap is aligned to the right side of the intraabdominal esophagus. We still request the anesthesiologist to accelerate the bougie (48 or 52 french) into the tummy earlier completing this footstep. One time the bougie is successfully avant-garde, the posterior fundoplication is built. Three stitches are placed along the right fundic flap and the esophagus without involving the inductive vagus nervus. The upper sew together includes the diaphragm and the esophagus as a coronal technique. The aforementioned sequence is used to build the left fundic flap to the esophagus. Every bit in the total, the partial fundoplication is completed with an additional stitch, which is placed betwixt the correct fundic flap and the mesh/closed crura to counteract the twisting move of the fundoplication back to the left upper quadrant. Effigy eleven shows the completed partial fundoplication.
Completed partial fundoplication.
Tabular array i shows all the technical elements we always apply during our robotic technique in the setting of large giant hiatal hernias.
Table i.
Technical Elements of Robotic Fundoplication for Large Paraesophageal Hiatal Hernia
| Elements |
| Reduce the hernia sac from the hiatus, not from the mediastinum |
| Take down the short gastric vessels |
| Mobilize the unabridged stomach, including the posterior gastric wall |
| Bougie size |
| Close of the diaphragmatic crura |
| Placement of biosynthetic absorbable mesh |
| Blazon of fundoplication (total versus partial) |
| Length of fundoplication |
| Infinite between the fundoplication and the esophagus |
| Anchoring the fundoplication to the esophagus |
| Anchoring the fundoplication to the diaphragm |
RESULTS
All patients were completed robotically. Fifty-eight patients underwent full fundoplication, 11 patients underwent partial fundoplication and one patient required Collis-Nissen fundoplication for an acquired curt esophagus. We were able to attain a sufficient intestinal length of the distal esophagus in almost all accomplice of patients. Nosotros believe the consummate removal of the hernia sac and taking down all the fibrotic adhesions between the distal third of the esophagus and the surrounding hiatal hernia structures helped u.s.a. to achieve this result. Biosynthetic absorbable mesh was applied to reinforce the crura closure in all patients but the first seven patients in our before experience. In the first few patients, nosotros noticed absence of tension at the diaphragmatic level after completing the crura closure. Additional concurrent robotic procedures included two Morgagni hernias repaired with mesh, one cholecystectomy, one excision of gastric leiomyoma, two ventral hernias repaired with mesh, one umbilical hernia repair with mesh, two unilateral inguinal hernias repaired with mesh, and i bilateral inguinal hernia repaired with mesh. Mean operative time was 223 min (180–360), considering docking time to undocking time. Intraoperatively, we experienced 2 gastric perforations while mobilizing the large hiatal hernias. Both perforations were repaired in double-layer suture using the robotic platform. One patient experienced intraoperative right pneumothorax, which was initially controlled by our anesthesiologists and later on required a placement of breast tube at the cease of the procedure. No intraoperative blood transfusions were required and no anesthesia complications were experienced. In addition, no intraoperative or perioperative mortality were recorded. After a brief stay in the recovery unit, all patients were admitted for an overnight stay. A clear liquid diet was resumed the evening of the performance and the patient was kept on full liquid diet for the following two weeks before advancing to regular nutrition. Among our 70 patients with large giant hiatal hernias, 90% were discharged later 24 h from surgery, whereas the remaining 10% went home later on 48–96 h. Patients were asked to be followed-up clinically at 14 d, thirty d, iii mo, six mo, and yearly later on surgery. UGI series were ordered at 6 mo and 1 y postoperatively, regardless of their symptomatology. Just 43 patients were studied with this methodology based on their understanding and their insurance authorization. Iii patients experienced bilateral pulmonary emboli, presenting as chest pain and acute shortness of breath, while in the hospital. Pulmonary emboli were confirmed by computed tomography angiography of the breast and treated without further sequelae. One patient required an emergent exploratory laparotomy for postoperative haemorrhage at 72 h. Two patients were diagnosed with postoperative rapid atrial fibrillation at 2 and 3 d later surgery, and they converted to sinus rhythm after medical intervention. Figure 12 shows the clinical outcome of our patient population at the median follow-up of 29 mo (vii–51). Viii patients experienced balmy dysphagia for solid foods for an average of 12 wk after surgery. Eventually, all patients resolved information technology without the need for esophageal dilation. No patients experienced persistent de novo dysphagia at the 6-mo follow-upwardly. 80 per cent of patients experienced severe dysphagia preoperatively, which resolved postoperatively in 94% of them at follow-up. These results are comparable with an earlier series examining laparoscopic antireflux surgery.11 Six patients (8.5%) recurred. Four were symptomatic and they were treated with redo-robotic fundoplication with additional mesh placement. Three of the 4 patients were converted to open approach because of astringent scar tissue effectually the hiatus, probably secondary to the fibrotic reaction created by the absorbable mesh. Based on the difficult beefcake, i patient underwent wedge resection at the fundus level with an anterior fundoplication and gastropexy as final arroyo. The remaining three patients had a concurrent gastropexy in addition to the fundoplication. The other 2 asymptomatic patients were found to have a small hiatal hernia by UGI series, and they are currently existence followed up clinically, with only medical intervention.
Clinical outcome at 29 mo median follow-upwards.
DISCUSSION
Robotic surgery is gaining major popularity in treating more complicated cases in the gastrointestinal surgical loonshit, including cholecystectomy, colectomy, splenectomy, gastrectom,y and pancreatectomy. The benefit of minimally invasive surgery to treat gastroesophageal reflux and sliding hiatal hernia has been established.ii We recently published our robotic experience in treating gastroesophageal reflux disease associated with sliding hiatal hernia or paraesophageal hernias, obtaining excellent clinical outcomes.13 We focused on the strict application of surgical steps that, if followed, they should help the surgeon to obtain excellent outcome, minimizing intraoperative and postoperative complications. We too underlying the part of the robotic platform to treat successfully more complicated foregut surgeries, like large paraesophageal hernias. This prospective review focuses on robotic surgical repair of large paraesophageal hernia providing the function of those surgical principles and proving their importance in obtaining excellent clinical outcome in a longer follow up (median 29 mo). There have only been a few reports examining robotic fundoplication and paraesophageal hernia repair in the terminal decade.fourteen–16 Our prospective feel compares well with those robotic reported series focusing on safety and feasibility of large paraesophageal hernia repair. To the all-time of our knowledge, antireflux surgery is the only general surgery application of robotic technique for which form I show is bachelor. There are a few studies comparing robotic versus laparoscopic fundoplication for GERD and hiatal hernia repair.17–25 We abet of the use of total versus partial fundoplication. Regardless of the type of fundoplication, a thorough preoperative assessment is critical to delineate a patient's anatomy and later on, platonic treatment.9 This evaluation includes preoperative esophagogastroduodenoscopy, UGI serial, esophageal manometry, and 24–48 h pH monitoring study to select what kind of fundoplication should be performed. Large paraesophageal hiatal hernias correspond most our patients with or without GERD in our clinical practice, and several patients have as well presented acutely with severe breast pain and dysphagia secondary to gastric volvulus and organo-axial rotation of the stomach in the chest. In those patients, preoperative workup included esophagogastroduodenoscopy and computed tomography browse of the breast. This predominance, in our community practice, suggests the possible development of small sliding hiatal hernias when treated with only proton pump inhibitors condign giant hiatal hernias over several years. The utilize of the biosynthetic absorbable mesh was decided intraoperatively. In our prospective series, seven patients did not require the utilization of the mesh because of the absence of tension in endmost the diaphragmatic pilasters subsequently reducing the stomach into the abdomen. The remaining 63 patients required a U-shape mesh placement for reinforcement, and at present information technology became our standard of practice. We did not experience any mesh related complications at 29 mo median follow-up. Stadlhuber et al. described mesh related complications in laparoscopic antireflux surgery, but the utilized mesh was constructed.26 Our mesh is absorbable over a relatively short period (3–6 mo). We believe the absence of mesh related complications is due to its absorbable property. Similar results were recently published by Dr. DeMeester's group using NoneCross-linked human dermal mesh27 or Phasix Sepra-Technology (Phasix-ST mesh).28 Oelschlager et al. reported the longest follow up after using biological mesh for big paraesophageal hiatal hernia.29 Unfortunately, their results proved that the benefit in reducing big hiatal hernia recurrence diminishes at long-term follow-up. Nosotros plan on long-term follow-up for our patients to discover remote recurrence. One limit of our prospective experience is the relative short follow-up with the mesh reinforcement. We need longer follow-up to identify any potential long-term effect of mesh utilize and the clinical outcome of our robotic experience.
Nosotros did non experience any mortality in our group. One patient experienced a right pneumothorax, which was successfully treated with chest tube placement. Our postoperative complications (10%) included three bilateral pulmonary emboli, two new onset of atrial fibrillation and severe urinary retention, a delayed hemoperitoneum detected 3 days after surgery. All complications were treated successfully. These rates are comparable with a large reported series examining standard laparoscopic paraesophageal hernia repair.xxx Most our patients were elderly (above 65 y old), Nosotros reviewed their intraoperative experience, postoperative course, and clinical result, and we proved that age should not be a limiting gene in treating large paraesophageal hernia.31 In the recent past, patients with acutely symptomatic paraesophageal hernia were treated with open surgery. In our exercise, we have been able to offer to these acutely sick patients robotic surgery in an expedited fashion, usually inside 24 h of admission. We believe an established robotic program in the hospital is behind this prompt intervention. This expedited surgical intervention might explain the absence of intraoperative or perioperative mortality in our patient population. This strategy was confirmed past other groups in recent reports.32,33
We experienced 6 recurrences in our serial (8.5%). 4 patients underwent attempted robotic approach with REDO fundoplication, closure of the hiatus, new mesh placement and concurrent gastropexy. Iii patients were converted to open up procedure due to severe scar tissue between the hiatus and the disrupted fundoplication. We believe the previous presence of the mesh made the REDO operation very challenging and lengthening, leading to our higher conversion charge per unit.34 These information were non reported previously in REDO fundoplication literature. The other two patients were found with recurrent hiatal hernia by routine upper gastrointestinal serial ordered at ane y and xviii mo in follow-up. They were both asymptomatic and followed up clinically and pharmacologically. These rates are lower than other published serial in laparoscopic surgery in which recurrence has been almost 23–43%.35,36 Recently, Fei et al. hypothesized that ultrastructural illness of diaphragmatic pillars might be implicated in this high recurrence.37 The authors proved that 94% of muscular samples coming from the crura were altered on microscopic view. Those findings suggest that the outcome of antireflux surgery could depend not only on the adopted surgical technique just also on the underlying condition of the diaphragmatic crura.
We believe the robotic approach helps to accomplish excellent long-term results in treating those large hiatal hernias. Our ii and half years median follow-upward does not help us to conclude the very long-term success of robotic surgery in this very challenging disease. Nosotros demand college number of patients and longer follow-up with prospective randomized studies to achieve those information. In our experience, we use all the technical elements previously described in the laparoscopic era in performing the fundoplication.9,12,13 The dexterity of robotic surgery helps the surgeon add precision in every task related to this very difficult functional gastrointestinal disorder, compared with the laparoscopic arroyo.
Determination
We described in detail the robotic operative technique for total and partial fundoplication in treating large paraesophageal hiatal hernias, many of those with almost the unabridged tum in the chest. We almost e'er add a biological absorbable mesh in those patients. The robotic REDO fundoplications are very challenging with high conversion rate, probably because of the use of biological absorbable mesh. We believe the long-term successful event is linked to all the technical elements related to the full and partial fundoplication techniques. The high dexterity of robotic surgery helps u.s.a. to achieve the durable clinical effect in this very difficult and common subgroup of patients in our clinical practice.
Acknowledgments
Authors would like to acknowledge Mrs Lindsey Marie Vasquez'due south contribution in helping to review the manuscript in its grammar rules and linguistic communication, making it more elegant for the journal.
Contributor Information
Massimo Arcerito, Riverside Medical Clinic Inc., University of California Riverside Schoolhouse of Medicine, Riverside, California. Sectionalisation of Full general and Vascular Surgery, Riverside Customs Hospital, Riverside, California. Riverside Community Hospital, Riverside, California and Division of General and Vascular Surgery, Rancho Leap Medical Center, Murrieta Temescal Valley California.
Martin G. Perez, Riverside Medical Clinic Inc., University of California Riverside Schoolhouse of Medicine, Riverside, California. Segmentation of General and Vascular Surgery, Riverside Community Hospital, Riverside, California.
Harpreet Kaur, Partitioning of General and Vascular Surgery, Riverside Community Hospital, Riverside, California.
Kenneth K. Annoreno, Division of General and Vascular Surgery, Riverside Community Infirmary, Riverside, California.
John T. Moon, Shawnee Mission Medical Middle, Shawnee Mission, Kansas.
References:
1. Soper NJ, Stockmann PT, Dunnegan DL, Ashley SW. Laparoscopic cholecystectomy. The new 'gold standard'? Arch Surg. 1992;127:917. [PubMed] [Google Scholar]
2. Patti MG, Robinson T, Galvani C, Gorodner MV, Fisichella PM, Way LW. Full fundoplication is superior to fractional fundoplication even when esophageal peristalsis is weak. J Am Coll Surg. 2004;198:863– 869. [PubMed] [Google Scholar]
3. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292–300. [PubMed] [Google Scholar]
4. Patti MG, Diener U, Tamburini A, Molena D, Mode LW. Role of esophageal part tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci. 2001;46:597–602. [PubMed] [Google Scholar]
5. Broeders JAJL, Mauritz FA, Ahmed Ali U, et al. Systematic review and meta-analysis of laparoscopic Nissen (posterior total) versus Toupet (posterior partial) fundoplication for gastrooesophageal reflux disease. Br J Surg. 2022;97:1318–1330. [PubMed] [Google Scholar]
6. Asti Eastward, Lovece A, Bonavina 50, et al. Laparoscopic direction of large hiatus hernia: 5-year cohort study and comparing of mesh augmented versus standard crura repair. Surg Endosc. 2022;thirty:5404–5409. [PubMed] [Google Scholar]
seven. Oleynikov D, Eubanks TR, Oelschlager BK, Pellegrini CA. Total fundoplication is the performance of choice for patients with gastroesophageal reflux and lacking peristalsis. Surg Endosc. 2002;16:909–913. [PubMed] [Google Scholar]
eight. Musunuru S, Gould JC. Perioperative outcomes of surgical procedures for symptomatic fundoplication failure: a retrospective case-control study. Surg Endosc. 2022;26:838–842. [PubMed] [Google Scholar]
ix. Patti MG, Arcerito M, Feo CV, et al. An assay of operations for gastroesophageal reflux disease. Identifying the of import technical elements. Arch Surg. 1998;133:600–606. [PubMed] [Google Scholar]
10. Patti MG, De Bellis 1000, De Pinto M, et al. Partial fundoplication for gastroesophageal reflux. Surg Endosc. 1997;11:445–448, [PubMed] [Google Scholar]
11. Patti MG, Feo CV, De Pinto Thou, Arcerito M, Tong J, Gantert W, Tyrrell D, Style LW. Results of laparoscopic antireflux surgery for dysphagia and gastroesophageal reflux illness. Am J Surg. 1998;176:564–568. [PubMed] [Google Scholar]
12. Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg. 1998;186:428–432, Apr; discussion 432–433. [PubMed] [Google Scholar]
13. Arcerito Chiliad, Changchien E, Falcon Chiliad, Parga MA, Bernal O, Moon JT. Robotic fundoplication for gastroesophageal reflux disease and hiatal hernia: initial experience and consequence. Am Surg. 2022;84:1945–1950. [PubMed] [Google Scholar]
14. Gehrig T, Mehrabi A, Fischer Fifty, et al. Robotic-assisted paraesophageal hernia repair: a case–control study. Langenbecks Curvation Surg. 2022;398:691–696. [PubMed] [Google Scholar]
15. Draaisma WA, Gooszen HG, Consten EC, Broeders IA. Mid-term results of robot assisted laparoscopic repair of big hiatal hernia: a symptomatic and radiological prospective cohort written report. Surg Technol Int. 2008;17:165–170. [PubMed] [Google Scholar]
16. Galvani CA, Loebl H, Osuchukwu O, Samame J, Apel ME, Ghaderi I. Robotic assisted paraesophageal hernia repair: initial experience at a single institution. J Laparoendosc Adv Surg Tech. 2022;26:290–295. [PubMed] [Google Scholar]
17. Muller-Stich BP, Reiter MA, Wente MN, et al. Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a airplane pilot randomized controlled trial. Surg Endosc. 2007;21:1800–1805. [PubMed] [Google Scholar]
18. Draaisma WA, Ruurda JP, Scheffer RC, et al. Randomized clinical trial of standard laparoscopic versus robot-assisted laparoscopic Nissen fundoplication for gastroesophageal reflux disease. Br J Surg. 2006;93:1351–1359. [PubMed] [Google Scholar]
xix. Morino Chiliad, Pellegrino 50, Giaccone C, Garrone C, Rebecchi F. Randomized clinical trial of robot-assisted versus laparoscopic Nissen fundoplication. Br J Surg. 2006;93:553–558. [PubMed] [Google Scholar]
20. Nakadi IE, Melot C, Closset J, et al. Evaluation of da Vinci Nissen fundoplication clinical results and cost minimization. World J Surg. 2006;30:1050–1054. [PubMed] [Google Scholar]
21. Hartmann J, Menenakos C, Ordemann J, Nocon M, Raue Westward, Braumann C. Long-term results of quality of life after standard laparoscopic vs robot-assisted laparoscopic fundoplications for gastroesophageal reflux disease: a comparative clinical trial. Int J Med Robot. 2009;5:32–37. [PubMed] [Google Scholar]
22. Heemskerk J, van Gemert WG, Greve JW, Bouvy ND. Robot-assisted versus conventional laparoscopic Nissen fundoplication: a comparative retrospective study on costs and time consumption. Surg Laparosc Endosc Percutan Tech. 2007;17:1–iv. [PubMed] [Google Scholar]
23. Ayav A, Bresler 50, Brunaud L, Boissel P. Early results of ane-year robotic surgery using the Da Vinci system to perform advanced laparoscopic procedures. J Gastrointest Surg. 2004;8:720–726. [PubMed] [Google Scholar]
24. Giulianotti PC, Coratti A, Angelini M, et al. Robotics in general surgery: personal feel in a large customs hospital. Curvation Surg. 2003;138:777–784. [PubMed] [Google Scholar]
25. Melvin WS, Needleman BJ, Krause KR, Schneider C, Ellison EC. Computer-enhanced vs. standard laparoscopic antireflux surgery. J Gastrointest Surg. 2002;6:11–xv. [PubMed] [Google Scholar]
26. Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications later on prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009. ;23:1219–12326. [PubMed] [Google Scholar]
27. Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, collis gastroplasty, and NoneCross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg. 2022;219:988– 992. [PubMed] [Google Scholar]
28. Abdelmoaty WF, Dunst CM1, Filicori F, et al. Combination of surgical technique and bioresorbable mesh reinforcement of the crural repair leads to low early on hernia recurrence rates with laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 2022. [Epub ahead of print]. [PubMed] [Google Scholar]
29. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence later laparoscopic paraesophageal hernia repair: long-term follow up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2022;213:461–468. [PubMed] [Google Scholar]
30. Gangopadhyay N, Perrone JM, Soper NJ, et al. Outcomes of laparoscopic paraesophageal hernia repair in elderly and high risk patients. Surgery 2006;140:491–498. [PubMed] [Google Scholar]
31. Arcerito M, Moon JT. Robotic fundoplication for gastroesophageal reflux disease and hiatal hernia in elderly. Gastroenterology. 2022;154:S-1323. [PubMed] [Google Scholar]
32. Bhayani NH, Kurian AA, Sharata AM, Reavis KM, Dunst CM, Swanstrom LL. Look just to resuscitate: early surgery for acutely presenting paraesophageal hernias yields better outcomes. Surg Endosc. 2022;27:267–271. [PubMed] [Google Scholar]
33. Parker DM, Rambhajan A, Johanson K, Ibele A, Gabrielsen JD, Petrick AT. Urgent laparoscopic repair of acutely symptomatic PEH is safety and effective. Surg Endosc. 2022;27:4081–4086. [PubMed] [Google Scholar]
34. Arcerito M, Kaur H, Mood JT. Robotic fundoplications for giant paraesophageal hernia: role of biosynthetic tissue reinforcement subsequently cruroplasty. Gastroenterology. 2022;156:S-1485–Southward-1486. [Google Scholar]
35. Altorki NK, Yankelevitz D, Skinner DB. Massive hiatal hernias: the anatomic basis of repair. J Thorac Cardiovasc Surg. 1998;115:828–835. [PubMed] [Google Scholar]
36. Hogan Due south, Pohi D, Bogetti D, Eubanks T, Pellegrini C. Failed antireflux surgery. Arch Surg. 1999;134:809–817. [PubMed] [Google Scholar]
37. Fei Fifty, Del Genio SM, Rossetti GL, et al. Hiatal hernia recurrence: surgical complication or disease? Electron Microscope Findings of the Diaphragmatic Pillars J Gastrointest Surg. 2009;xiii:459–464. [PubMed] [Google Scholar]
Articles from JSLS : Journal of the Society of Laparoscopic & Robotic Surgeons are provided here courtesy of Society of Laparoscopic & Robotic Surgeons
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7065729/
Posted by: lindnermung1940.blogspot.com
0 Response to "How Is A Hiatal Hernia Repaired Using Robotics"
Post a Comment