What are the steps for robotic hiatal hernia repair?

Robotic Hiatal Hernia Repair: Step-by-Step Approach

Robotic hiatal hernia repair is a minimally invasive surgical approach that demonstrates favorable short-term outcomes compared to laparoscopic repair, with lower complication rates and shorter hospital stays. 1

Patient Selection and Preparation

• Assess patient stability:

  • Stable patients without signs of strangulation or peritonitis are suitable candidates for robotic repair
  • Unstable patients or those with severe sepsis/septic shock may require open surgical management 2

• Optimize modifiable risk factors before elective surgery:

  • Smoking cessation
  • Diabetes control (HbA1C <7%)
  • Weight management (BMI <40 kg/m²)

• Consider thromboprophylaxis:

  • Risk factors include age >40 years, BMI >30 kg/m², and operation duration >2 hours 3
  • Heparin should be commenced 6-8 hours post-operatively

Surgical Steps for Robotic Hiatal Hernia Repair

1. Patient Positioning and Port Placement

   • Position patient in reverse Trendelenburg
   • Place ports in appropriate configuration for robotic system access
   • Dock the robot

2. Hernia Sac Identification and Reduction

   • Identify and reduce the hernia sac
   • Completely mobilize the esophagus
   • Ensure adequate intra-abdominal esophageal length (at least 2-3 cm)

3. Crural Repair

   • Dissect and expose the diaphragmatic crura
   • Perform primary repair of the diaphragmatic defect using non-absorbable sutures 2
   • For defects >3 cm that cannot be closed primarily, use mesh reinforcement 2
   • When using mesh:
     • Ensure mesh overlaps the defect edge by 1.5-2.5 cm 2
     • Avoid tackers near the pericardium to prevent cardiac complications 2

4. Fundoplication Procedure

   • Perform fundoplication based on patient's symptoms and anatomy
   • Nissen or Toupet fundoplication are common options
   • Toupet fundoplication may have lower recurrence rates compared to Nissen 2, 4

5. Additional Procedures as Needed

   • For gastric volvulus: perform gastropexy after detorsion 2
   • For patients with history of gastroesophageal reflux: consider fundoplication 2
   • For shortened esophagus: consider Collis procedure 2

Technical Considerations

• Mesh selection:

  • For clean cases: polypropylene mesh is considered standard
  • For clean-contaminated or contaminated repairs: biologic or biosynthetic meshes are preferred 2
  • PTFE (Gore-Tex™) is commonly recommended for diaphragmatic reconstruction due to its strength and reduced risk of bowel adhesion 2

• Robotic advantages:

  • Improved visualization and dexterity in the confined space of the hiatus
  • Better suturing capabilities for primary crural repair
  • Lower complication rates (6.3% vs 19.2%) compared to laparoscopic approach 1

Postoperative Management

• Multimodal pain management:

  • Non-opioid medications as first-line (acetaminophen, NSAIDs)
  • Limited opioid prescription if needed

• Early mobilization to prevent complications

• Monitor for common complications:

  • Pulmonary complications including atelectasis
  • Hematoma (1.6-1.86%)
  • Seroma (0.4%)
  • Wound infection (0.4-1.6%)
  • Recurrence

Learning Curve Considerations

• The early robotic hiatal hernia repair experience can be challenging even for experienced laparoscopic surgeons 5
• Operative times significantly decrease with experience (184 min in early experience vs 142 min in late experience) 5
• Conversion rates also decrease with experience (30.8% in early experience vs 0% in late experience) 5

Outcomes

• Robotic hiatal hernia repair demonstrates:
  • Shorter hospital stay (1.3 ± 1.8 vs 1.8 ± 1.5 days) 1
  • Lower complication rates compared to laparoscopic approach 1, 6
  • Satisfactory quality of life outcomes 4
  • Low short-term recurrence rates 4

The robotic approach to hiatal hernia repair offers significant advantages over traditional laparoscopic techniques, particularly in complex cases requiring extensive dissection and suturing. As surgeon experience increases, operative times decrease and outcomes improve.