Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair

Morbidity of emergent versus elective hiatal hernia repair: an analysis of the NIS database

BACKGROUND

Elective hiatal hernia repair (HHR) is associated with reduced morbidity compared to emergent HHR. However, few studies examine the specific factors contributing to morbidity in emergent HHR. This study uses the National Inpatient Sample (NIS) database to compare the morbidity of emergent versus non-emergent HHR and identify associated risk factors.

METHODS

Data from the NIS (2016-2021) were analyzed for all patients undergoing HHR. Health factors, including demographics, comorbidities, and operative details, were compared using chi-squared and T-tests. A multivariable logistic regression model was created to identify factors associated with morbidity, defined as postoperative complications such as sepsis, pneumonia, myocardial infarction, deep venous thrombosis (DVT), pulmonary embolism (PE), and others.

RESULTS

A total of 723,000 records existed with a hiatal hernia diagnosis code. Of these, 67,059 patients underwent HHR, with 61,586 (91.8%) undergoing non-emergent HHR. Emergent HHR was associated with increased morbidity (OR 3.95, 95% CI 1.0-1.05, p < 0.05). Risk factors for increased morbidity in both groups included hypertension and advanced age. Protective factors included female gender, GERD, and prior bariatric surgery. Diabetes increased morbidity in emergent HHR but not non-emergent HHR. Smoking, Medicare/Medicaid, mesh use, COPD, and history of DVT increased morbidity in elective HHR, but not emergent HHR. The robotic approach increased morbidity in non-emergent HHR but decreased it in emergent HHR.

CONCLUSION

Emergent HHR is associated with higher morbidity compared to non-emergent HHR. Risk factors like smoking, COPD, and DVT increase morbidity in non-emergent HHR, while female gender, GERD, and prior bariatric surgery are protective. The NIS database provides valuable insights into the morbidity associated with HHR and can guide surgical decision-making.

Comparison of da Vinci Robot-Assisted and Conventional Laparoscopic Surgery for Hiatal Hernia in Children after Repair for Esophageal Atresia

Objective: To compare the effectiveness and safety of da Vinci robot-assisted and conventional laparoscopic surgery for hiatal hernia (HH) treatment in children after repair of esophageal atresia (EA). Methods: A retrospective analysis was conducted of 54 children with EA who underwent either conventional or robot-assisted laparoscopic HH repair between January 2018 and December 2023 in our center. Clinical characteristics and postoperative outcomes were compared to explore the effectiveness and safety of both surgical methods. Results: Fifty-four patients (conventional surgery, n = 32; robot-assisted surgery, n = 22) met the inclusion criteria. No significant difference was found in gender, age, EA repair method, main symptoms, HH type, and previous HH repair between the two groups. Type A EA accounted for more proportion in conventional surgery group (43.8% versus 13.6%, P < .05). There was a higher use of Nissen fundoplication in robot-assisted surgery group (78.1% versus 100%, P < .05). No significant difference was found in terms of operation length, blood loss, time to start enteral nutrition, conversion to open and total, or postoperative length of stay. The incidence of recurrent symptoms, especially reflux during nighttime, was significantly higher in conventional surgery group (31.3% versus 0%, P < .05). No severe complication or death was reported in either group. Conclusions: Robot-assisted laparoscopic surgery can be performed safely and effectively for HH repair in EA patients, which made Nissen fundoplication more feasible and showed superior control of reflux symptoms than conventional laparoscopic surgery.

Voluminous hiatal hernias - the role of robotic surgery

Robotic surgery has become increasingly prevalent in UGI surgery over the last decade, particularly for treating hiatal hernias. Voluminous hiatal hernias, defined as the herniation of 30-50 % of the stomach into the thorax, often require surgical intervention due to associated dysphagia and potential severe complications. Given the challenges of repairing voluminous hiatal hernias, especially in elderly and fragile patients, the surgical technique should be optimal. Robotic surgery affords excellent visualization, allowing high mediastinal dissection and precise hiatus reconstruction. Despite the clear technical advantages, it remains to be demonstrated if the robotic approach matches the outcomes of conventional laparoscopic techniques. We review here the fundamentals of hiatal hernia surgery and describe our surgical technique using the da Vinci Xi robot to operate voluminous hiatal hernias. Additionally, we performed a systematic research analysis and selected recent publications focusing on robotic surgery for voluminous hiatal hernias. Recent studies report comparable complication rates, recurrence, and hospital stay lengths between robotic and laparoscopy surgery. Initial robotic procedures had longer operative times, which decreased with surgeon experience. Most of the studies were observational and retrospective, reporting the experience of a single center. Robotic surgery appears to be a viable option with similar complications rates to laparoscopic surgery under optimized conditions. Current literature supports the broader adoption of robotic surgery for voluminous hiatal hernias. However, prospective randomized studies are needed to further validate its use.

Robotic surgery for giant paraesophageal hernias: a promising approach to improved outcomes

Giant paraesophageal hernias (GPEH) present challenges in management and surgical technique. Laparoscopic repair has been the gold standard for GPEH repair. Despite technical advances in laparoscopy, complications and recurrence remain high. The da Vinci Surgical System has emerged as a way to improve upon the gold standard. The objective of this study is to evaluate clinical outcomes of patients who underwent robotic GPEH repair in comparison to the clinical data in the literature on laparoscopic GPEH repair. We retrospectively reviewed patient records who underwent GPEH repair between November 2012 and February 2023 at a single high-volume tertiary care center. Perioperative data and patient outcomes were collected from a prospectively maintained database. Ninety-two patients underwent robotic GPEH repair. Sixty-seven had Type III hernias (72.8%) and twenty-five had Type IV hernias (27.2%). Four (4.3%) required conversion to open repair and two (2.2%) required reoperation for recurrence. Twelve (13.0%) experienced complications including one surgical complication (splenic laceration) and eleven medical complications (fever, ileus, pleural effusion, and heart failure exacerbation). There was no perioperative mortality. Mean operative time was 166.4 ± 29.5 min, and hospital stay was 5.8 ± 3.1 days. Obesity (BMI > 30) was associated with higher complication and recurrence rates. Robotic GPEH repair demonstrates promising outcomes, with lower recurrence rates and fewer postoperative complications compared to published data on laparoscopic repair. While a randomized control trial is needed to substantiate these results, our data support that a robotic approach could become the standard of care for GPEH repair.

Hiatal Hernia Repair: A Century Between Soresi and da Vinci

A minimally invasive approach is the most common technique for hiatal hernia repair. The robotic platform offers a unique advantage that addresses the limitations of a laparoscopic repair. The steps of a robotic hiatal hernia repair include reduction of hernia contents, dissection of hernia sac, circumferential dissection of esophagus with 2.5 to 3 cm of intraabdominal esophagus, crural closure, and partial or complete fundoplication. The robotic hiatal hernia repair has comparable perioperative outcomes to the laparoscopic approach. This article discusses current controversies, limitations, and new technologies.

Complications After Paraesophageal Hernia Repair

Paraesophageal hernia repair (PEHR) is a challenging operation both technically and because the affected patient population is typically older with more comorbidities. As a result, PEHR is associated with substantial morbidity. Morbidity and mortality following PEHR vary significantly depending on the acuity of the operation and size of the hernia. In addition to a higher risk for general peri- and postoperative complications there are a variety of other foregut specific complications to consider including, acute perioperative, early, and late reherniation, mesh-related complications, perforation, gastroparesis, pulmonary and insufflation-related complications, among others. This review focuses on the complication-specific data on incidence, recognition etiology and management.

Perioperative outcomes of robotic versus laparoscopic paraesophageal hernia repair: a NSQIP analysis

BACKGROUND

Studies comparing outcomes between robotic and laparoscopic paraesophageal hernia repairs have yielded conflicting results. We sought to analyze early postoperative complications between these approaches using a newly available NSQIP variable indicating robot use.

METHODS

We queried the 2022 ACS NSQIP database for adult patients undergoing elective minimally invasive hiatal hernia repair. Chi-squared and Kruskal-Wallis tests were used to compare cohort characteristics. Logistic, linear, and Cox proportional hazards regression analyses were used to compare perioperative outcomes between the laparoscopic and robotic groups.

RESULTS

We identified 4345 patients who underwent repair using a laparoscopic (2778 patients; 63.9%) or robotic (1567 patients; 36.1%) approach. Most (73.1%) were female, and the median age was 65 (IQR 55, 73). Patients who underwent robotic repair were younger (median age 64 vs 66), had a slightly higher body mass index (BMI; median 30.2 vs 29.9), and were more likely to have hypertension (53.0% vs 48.5%), all p < 0.01. On unadjusted analysis the robotic approach was associated with decreased 30-day mortality (0.0% vs 0.4%, p < 0.01). After adjusting for age, gender, race, BMI, and hypertension, the robotic approach was not associated with increased major complications (5.6% vs 5.1%, AOR 1.13, 95% CI 0.86, 1.49), minor complications (0.9% vs 1.5%, AOR 1.20, 95% CI 0.74, 1.93), or unplanned readmission (6.5% vs 5.5%, AHR 1.17, 95% CI 0.89, 1.54), all p ≥ 0.26. After adjusting for age and hypertension, the robotic cohort had an increased risk of myocardial infarction (AOR 2.53, 95% CI 1.01, 6.33, p = 0.048) and pulmonary embolism (AOR 2.76, 95% CI 1.17, 6.49, p = 0.02), although none resulted in 30-day mortality.

CONCLUSIONS

Robotic and laparoscopic paraesophageal hernia repairs had similar overall complication and readmission rates. The robotic cohort had an increased risk of myocardial infarction and pulmonary embolism but no 30-day mortality. Current data support the use of both robotic and laparoscopic approaches for paraesophageal hernia repair.

Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes

PURPOSE

The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques.

METHODS

We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis.

RESULTS

Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196 min for robotic compared to 145 min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88 min for robotic versus 102 min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20 ml for robotic versus 50 ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%).

CONCLUSIONS

Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis

PURPOSE

The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery.

METHODS

A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale.

RESULTS

Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS.

CONCLUSION

This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.

Evaluation of robot-assisted laparoscopic versus conventional laparoscopic hiatal hernia repair in children

Laparoscopic approach is the gold standard for repairing hiatal hernia (HH). Robotic technology is now widely accepted, but it is rarely used in children with HH. Our aim was to evaluate the clinical effect of robot-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS) in the treatment of HH in children. A retrospective study was carried out in patients undergoing elective robot-assisted laparoscopic or conventional laparoscopic HH repair at a tertiary academic hospital from January 2020 to December 2022, and patients who met the inclusion criteria were included in this study. We compared the characteristics and clinical results of patients to understand the effects of the two surgical methods. Forty-six patients (CLS, group 1, n = 25; RALS, group 2, n = 21) met the inclusion criteria. All operations were performed by one experienced pediatric surgeon. In this study, no significant differences were found in terms of gender, age, weight, size of HH, total operation times, the effective operation time (excluding setup time) and complications between group 1 and group 2. (P = 0.979, P = 0.438, P = 0.265, P = 0.800, P = 0.122, P = 0.427 and P = 0.478, respectively). However, the intraoperative bleeding, the intensive care unit (ICU) admission, postoperative hospital length of stay (LOS) and postoperative fasting time were significantly less for RALS (P = 0.016, P = 0.040, P = 0.035 and P = 0.025, respectively). Meanwhile, the overall charges were significantly higher in group 2 (P < 0.01). Despite higher charges for robotic-assisted HH repair, it is a safe and reliable alternative to CLS and was associated with better outcomes in children.

Robotic versus laparoscopic surgery for hiatal hernia repair: a systematic literature review and meta-analysis

The number of robotic hiatal hernia repairs (RHHR) is increasing. However, the superiority of this minimally invasive approach remains controversial. The aim of this study was to evaluate the available literature reporting on outcomes of RHHR compared with laparoscopic hiatal hernia repair (LHHR) in adult patients. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, PubMed, the Cochrane Library, and ClinicalTrials.gov databases were searched. Identified publications were reviewed independently by two authors. High heterogeneity was further explored through sensitivity analysis. The primary endpoint was the development of postoperative complications. Secondary endpoints included operation time, intraoperative complications, 30 day readmission rates and length of stay. The analysis was performed using Stata 17.0 software. A total of 7 studies totaling 10078 patients met the inclusion criteria. Five studies included postoperative complications. The postoperative complications rate was 4.25% (302/7111) in the LHHR group, and 3.49% (38/1088) in the RHHR group. Postoperative complications significantly decreased after RHHR compared with LHHR (OR 0.52; 95% CI 0.36 to 0.75, P = 0.000). Three studies involving 2176 patients reported length of hospital stay. In the three studies, the mean Length of hospital stay was 3.2 days in the RHHR group, and 4.2 days in the LHHR group. Length of hospital stay was decreased by a mean of 0.68 days for RHHR compared with LHHR (WMD, - 0.68 days; 95% CI - 1.32 to - 0.03, P = 0.02). There was no significant difference between the RHHR group and the LHHR group regarding operative time, intraoperative complications, and 30 day readmission (P > 0.05). Our research shows that RHHR may be the better option, as the approach decreases postoperative complications and length of hospital stay.

Robotic Primary and Revisional Hiatal Hernia Repair is Safe and Associated with Favorable Perioperative Outcomes: A Single Institution Experience

Background: Robotic hiatal hernia (HH) repair has been demonstrated to be feasible and safe. Recent conflicting reports have emerged on the higher incidence of perioperative complications with robotic HH repair when compared with laparoscopic repair. Materials and Methods: A retrospective review of a prospective database at an academic medical center for all robotic HH repairs performed by a high-volume foregut surgeon from 2018 to 2021 was performed. Outcome measures included operative time, estimated blood loss (EBL), length of stay (LOS), conversion rate, need for esophageal lengthening procedure, intra- and perioperative complications, and 30-day in-hospital mortality. Results: One hundred four patients were included in the analysis. Fifteen percent of patients had a type I HH, 2% had a type II, 73% had a type III, and 10% had a type IV HH. Eighty-four percent of cases were primary and 16% were revisional. Fifty-four percent of patients had mesh placed and 4.4% had an esophageal lengthening procedure. Mean EBL was 15 mL and mean operative time was 151 minutes. Median LOS was 2 days (interquartile range 1-2 days). There were zero conversions. Intraoperative complication rate was 1% and 30-day complication rate was 4%. The 30-day in-hospital mortality was zero. Conclusion: In this retrospective analysis of 114 consecutive robotic HH repairs performed, with 83% type III or IV HHs and 16% revisional hiatal cases, our results demonstrate favorable perioperative outcomes, with lower EBL, shorter LOS, lower complication rate, zero conversions, and comparable operative times compared with historical laparoscopic data.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis

Purpose

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence.

Methods

A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time.

Results

Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates.

Conclusion

Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

BACKGROUND

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

METHODS

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

RESULTS

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

CONCLUSIONS

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

Magnetic sphincter augmentation: laparoscopic or robotic approach?

Gastroesophageal reflux disease (GERD)-the pathologic reflux of gastric contents into the distal esophagus-is the most common benign disorder of the esophagus. Its incidence is at 10-20% of the Western population and it yearly cost of treatment in the USA in 9.3 billion dollars. Although first line treatment for the disorder is medical therapy with proton pump inhibitors, an estimated 30-40% of patients will continue to experience medically refractory GERD. In this population anti-reflux surgery can be offered. Traditional anti-reflux surgery is done via the Nissen fundoplication, a technically difficult surgery with uncomfortable side effects of bloating and inability to belch. Magnetic sphincter augmentation (MSA) of the lower esophagus via the LINX device was introduced a less technically challenging alternative to the Nissen. The LINX provides fewer side effects of bloating and inability to belch and has been adapted widely to the practice of anti-reflux surgery. In this paper we discuss the progression of surgical practices with the LINX, including an analysis of the laparoscopic and robotic approaches to MSA device implantation.

Surgical treatment of large and complicated hiatal hernias with the new resorbable mesh with hydrogel barrier (Phasix™ ST): a preliminary study

Evaluation of the efficacy and safety of the new monofilament fully resorbable mesh with hydrogel barrier (Phasix™ ST), for large and complex hiatal hernia repair. Between December 2017 and December 2020, 60 patients with large or complicated hiatal hernia were treated (40 robotic and 20 laparoscopic procedures). The mesh was placed after primary closure of the hiatal defect, in an onlay fashion around the esophagus, followed by 360^o fundoplication. Follow-up at 3, 6, 12, 18, 24 months from intervention included clinical evaluation and upper GI endoscopy. In cases of recurrence, radiologic survey and manometry were utilized. There were no conversions to open repair or significant postoperative incidents. Over a median follow-up of 21 months (range 3-36), no recurrences or mesh related complications were observed. From our early experience, Phasix™ ST mesh seems to be safe and effective for the reinforcement of crural defects in large and complex hiatal hernia.

Enhanced recovery after surgery (ERAS) decreases complications and reduces length of stay in foregut surgery patients

INTRODUCTION

Enhanced recovery after surgery (ERAS) programs provide a framework for optimal perioperative care to improve post-operative outcomes following surgical procedures. However, there is no consensus regarding an ERAS protocol following foregut surgery. The purpose of this study was to develop an ERAS protocol for these patients and determine whether they improved outcomes.

METHODS

An IRB approved prospectively maintained database was retrospectively reviewed for all patients undergoing benign minimally invasive foregut surgery from October 2018 to January 2020. All patients were entered into the ACS risk calculator to determine their predicted rate of complications and length of stay for comparison between the ERAS and control groups. Propensity matching was used to compare post-ERAS implementation to pre-ERAS implementation patients. Firth logistic and Poisson regression analysis were used to assess the rate of complications and length of stay among the different groups of patients.

RESULTS

There were 255 patients (60 Post-ERAS, 195 Pre-ERAS) who underwent foregut operations and met inclusion criteria. ERAS was implemented, and patients were then subdivided based on those who completed ERAS (44) and those who deviated from the protocol (16). Propensity matching analysis was performed to compare the different cohorts and showed ERAS patients had 41% decreased odds of complications and 33% reduction in length of stay compared to pre-ERAS patients. Completion of the ERAS protocol resulted in even further reductions in odds of complication and length of stay compared to patients who deviated from the protocol.

CONCLUSIONS

ERAS has shown to improve perioperative outcomes, but there is limited literature supporting the use of ERAS in foregut surgery. Usage of an ERAS protocol can decrease complications and reduce the length of stay in patients.

Robotic-assisted foregut surgery is associated with lower rates of complication and shorter post-operative length of stay

BACKGROUND

Two of the most common foregut operations are laparoscopic Heller myotomy and laparoscopic Nissen fundoplication. Robotic assistance, compared to standard laparoscopic approach, may potentially grant surgeons advantages such as enhanced visualization and dexterity. This study compares patient outcomes for Heller myotomy (HM) and Nissen fundoplication (NF) when performed laparoscopically versus robotically.

METHODS

A retrospective review of patients at a single institution who underwent laparoscopic or robotic-assisted HM or NF from January 2019 to July 2022 was conducted. 123 HM (72 laparoscopic, 51 robotic-assisted) and 92 NF (62 laparoscopic, 30 robotic-assisted) were performed by three surgeons. Outcomes investigated were operative time, hospital length of stay, pre- and post-operative imaging, resolution of symptoms at 30 days, resolution of symptoms at 90 days, and complications.

RESULTS

In the HM cohorts, the average operative time was longer in the robotic cohort (127 min robotic versus 108 min laparoscopic, p < 0.01). However, overall complication rates (p < 0.05) were lower, and hospital length of stay was shorter in the robotic group (1.5 days compared to 2.7 days, p < 0.001). In the NF cohorts, there was no significant difference in operative time. However, hospital length of stay was shorter in the robotic group (1.54 days compared to 2.7 days, p < 0.001) with otherwise similar outcomes. There was no difference in the rate of post-operative resolution of symptoms or need for additional interventions in either HM or NF.

CONCLUSION

Robotic-assisted HM and NF are associated with shorter hospital stays compared to their respective laparoscopic approaches. Robotic-assisted HM also has a lower rate of complications. Our findings suggest that robotic assistance may be beneficial for shortening hospital length of stay and decreasing complications for certain surgeries specific to Foregut surgery.

Robotic operations in urgent general surgery: a systematic review

Robotically assisted operations are the state of the art in laparoscopic general surgery. They are established predominantly for elective operations. Since laparoscopy is widely used in urgent general surgery, the significance of robotic assistance in urgent operations is of interest. Currently, there are few data on robotic-assisted operations in urgent surgery. The aim of this study was to collect and classify the existing studies. A two-stage, PRISMA-compliant literature search of PubMed and the Cochrane Library was conducted. We analyzed all articles on robotic surgery associated with urgent general surgery resp. acute surgical diseases of the abdomen. Gynecological and urological diseases so as vascular surgery, except mesenterial ischemia, were excluded. Studies and case reports/series published between 1980 and 2021 were eligible for inclusion. In addition to a descriptive synopsis, various outcome parameters were systematically recorded. Fifty-two studies of operations for acute appendicitis and cholecystitis, hernias and acute conditions of the gastrointestinal tract were included. The level of evidence is low. Surgical robots in the narrow sense and robotic camera mounts were used. All narrow-sense robots are nonautonomous systems; in 82%, the Da Vinci^® system was used. The most frequently published emergency operations were urgent cholecystectomies (30 studies, 703 patients) followed by incarcerated hernias (9 studies, 199 patients). Feasibility of robotic operations was demonstrated for all indications. Neither robotic-specific problems nor extensive complication rates were reported. Various urgent operations in general surgery can be performed robotically without increased risk. The available data do not allow a final evidence-based assessment.

Robotic repair of post-oesophagectomy hiatal hernia

Diaphragmatic hiatal hernia is a potential complication of oesophagectomy in cancer patients. Over the past decades, laparoscopy has become the preferred approach to repairing this condition due to the reduced morbidity, faster recovery and shorter hospital stay when compared with traditional open surgery. The development of robotic technology has added to the benefits of minimally invasive approaches, offering potential technical advantages and overcoming some limitations of traditional laparoscopic techniques when performing complex procedures. We present the first report of a robotic post-oesophagectomy hiatal hernia repair.

Robot-assisted versus laparoscopic approach to concurrent bariatric surgery and hiatal hernia repair: propensity score matching analysis using the 2015-2018 MBSAQIP

BACKGROUND

Up to 37% of class three obesity patients have a Hiatal Hernia (HH). Most of the existent HHs get repaired at the time of bariatric surgery. Although the robotic platform might offer potential technical advantages over traditional laparoscopy, the clinical outcomes of the concurrent bariatric surgery and HH repair comparing robotic vs laparoscopic approaches have not been reported.

METHODS

Using the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, patients between 18 and 65 year old who underwent Sleeve gastrectomy (SG) or Roux en-Y Gastric Bypass (RYGB) with concurrent HH repair were identified. Demographic, operative, and 30-day postoperative outcomes data were compared between laparoscopic and robotic groups. To adjust for potential confounders, 1:1 propensity score matching was performed using 22 preoperative characteristics.

RESULTS

75,034 patients underwent SG (n = 61,458) or RYGB (n = 13,576) with concurrent HH repair. The operative time was significantly longer in the Robotic-assisted compared to the laparoscopic approach both for SG (102.31 ± 44 vs. 75.27 ± 37; P < 0.001) and for RYGB (163.48 ± 65 vs. 132.87 ± 57; P < 0.001). In the SG cohort (4639 matched cases), the robotic approach showed similar results in 30 day outcomes as in the laparoscopic approach, with no statistical difference. Conversely, for the RYGB cohort (1502 matched cases), the robotic approach showed significantly fewer requirements for blood transfusions (0.3% vs. 1.7%; P = 0.001), fewer anastomotic leaks (0.2% vs. 0.8%; P = 0.035), and less postoperative bleeding (0.4% vs. 1.1%; P = 0.049).

CONCLUSION

Robotic concurrent bariatric surgery and HH repair leads to similar overall clinical outcomes as the laparoscopic approach despite longer operative times. Furthermore, the robotic approach is associated with reduced blood transfusion and anastomotic leak incidence in the RYGB group.

Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair

INTRODUCTION

Complex and recurrent paraesophageal hernia repairs are a challenge for surgeons due to their high recurrence rates despite the use of various prosthetic and suturing techniques.

METHODS

Here we describe the use of vascularized fascia harvested from the posterior rectus sheath with peritoneum during robotic hiatal hernia repair in two patients with large complex diaphragmatic defects.

RESULTS

Successful harvesting and onlay of the right posterior rectus sheath based on a falciform vascular pedicle was achieved robotically by rotating and securing the flap to the diaphragmatic hiatus as an onlay flap following cruroplasty of the hiatal defect.

CONCLUSIONS

In patients with difficult to repair large paraesophageal hernias, we demonstrate a promising new technique to restore the dynamic hiatal complex with the tensile strength of autologous vascularized fascia and peritoneum.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].

Heller myotomy perforation: robotic visualization decreases perforation rate and revisional surgery is a perforation risk

Minimally invasive surgery (MIS) has improved surgical access to the foregut. While the benefits of MIS versus open surgery are well accepted, the relative benefits of laparoscopic versus robotic approaches continue to be debated. Procedure-specific comparisons are difficult to obtain for Heller myotomy, due to the relative rarity of the procedure in most practices. A retrospective review of prospectively collected perioperative data of a single surgical practice from 2001 to 2019 was conducted for the rate of perforation during Heller myotomy laparoscopically compared to robotically. From 2001 through February 2012, a laparoscopic approach was employed and from October 2008 to 2019, a robotic approach was employed. All perforations were recorded, as well as secondary outcomes of perforation location (gastric or esophageal), postoperative imaging for evidence of leak, length of stay, and complications. Chi-square and simple t test were employed for data analysis. During the 11 years of laparoscopic Heller myotomy, 14 cases resulted in 7 instances of perforation (50%). During the 11 years of robotic Heller myotomy, 45 cases resulted in 11 instances of perforation (24%) (p value = 0.06). All perforations in both groups were tiny, recognized, and repaired immediately. The length of stay (LOS) was longer in the laparoscopic perforation group (3.4 days) compared to the laparoscopic non-perforation group (1.2 days) (p value = 0.06). LOS for robotic was not significantly longer in the perforation group (2.8 days) compared to the robotic non-perforation group (1.5 days) (p value = 0.18). First time Heller myotomies showed a higher rate of perforation with laparoscopic (50%) vs robotic (14%) (p value = 0.009) approach. In subgroup analysis of revisional procedures, all ten were performed robotically (p value < 0.001) with a 60% perforation rate (p value = 0.001) and one associated, radiographically confirmed leak. Primary laparoscopic Heller myotomy related to more than four times the frequency of perforation than did primary robotic myotomy. We propose that the robotic platform provided the surgeon with superior ability to avoid perforation. Interestingly, the robotic group in this study dealt with more complex redo cases. In fact, reoperation in the area of the hiatus was a separate risk factor for perforation during robotic Heller myotomy. We recommend further prospective trials be done to better evaluate the benefits of robotic platform in regard to revisional foregut surgery.

Narrative review of management controversies for paraesophageal hernia

Objective

To review management controversies in paraesophageal hernia and options for surgical repair.

Background

Paraesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted.

Methods

Recent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes.

Conclusions

The extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the “reverse C” or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.

State-Level Examination of Clinical Outcomes and Costs for Robotic and Laparoscopic Approach to Diaphragmatic Hernia Repair

BACKGROUND

Published studies evaluating the effect of robotic assistance on clinical outcomes and costs of care in diaphragmatic hernia repair (DHR) have been limited.

STUDY DESIGN

The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing transabdominal DHR between 2011 and 2018 and associated inpatient and outpatient encounters within 12 months after the index operation. Patients undergoing robotic DHR were 1:1:1 propensity score-matched for age, sex, race, Elixhauser comorbidity score, case priority, payer, and facility volume with patients undergoing open and laparoscopic DHR.

RESULTS

There were 5,962 patients (67.3%) who underwent laparoscopic DHR, 1,520 (17.2%) who underwent open DHR, and 1,376 (15.5%) who underwent robotic DHR. On comparison of matched cohorts, median index length of stay (3 days; interquartile range [IQR] 2 to 5 days vs 2 days; IQR 1 to 4 days; p < 0.001) and index hospitalization costs ($17,236; IQR $13,231 to $22,183 vs $12,087; IQR $8,881 to $17,439; p < 0.001) for robotic DHR were greater than for laparoscopic DHR. Median length of stay for open DHR (6 days; IQR 4 to 10 days) was longer than that for both laparoscopic and robotic DHR. Median index hospitalization costs for open DHR ($16,470; IQR $11,152 to $23,768) were greater than those for laparoscopic DHR, but less than those for robotic DHR. There were no significant differences between cohorts in the overall rate of post-index care.

CONCLUSIONS

Laparoscopic DHR is the most cost-effective approach to DHR. Robotic assistance provides clinical outcomes comparable with laparoscopic DHR, but is associated with increased index cost.

A cost analysis of two- versus three-instrument robotic-assisted inguinal hernia repair with mesh: time is money

Equipment expenses and operating times can lead to higher costs with robotic surgery. We compared the cost-effectiveness of 2- vs. 3-instrument (2i vs. 3i) approach to robotic transabdominal preperitoneal inguinal hernia repair. We conducted a retrospective study of 172 patients, with 86 patients in each group. Procedure cost, operative time, morbidity, length of stay, readmission rate, and hernia recurrence at 90 days were compared. Statistical significance was assigned to p < 0.05. No significant differences in preoperative variables nor in postoperative outcomes were identified. Mean operative time was 6 min longer in the 2i group and this approach cost $300 less. The 2i approach was cost-effective for operating room (OR) costs of less than $50 per minute. Surgeon efficiency and OR dollar-per-minute value influence the potential for cost savings with fewer instruments in robotic herniorrhaphy. There is no difference in outcomes when fewer instruments are used.

Template for a program tailored ACS/APDS phase 1 curriculum: From needs assessment to implementation

BACKGROUND

The Phase 1 ACS/APDS skills curriculum standardizes intern training. Despite this, institutional implementation varies and is nationally low. We aimed to use Kern's six-steps to tailor this to our program, providing a framework to improve implementation.

METHODS

Problem identification and general needs assessment were performed. Targeted needs assessment (TNA) of incoming interns ('interns'), current residents, and attendings determined perceived importance of skills and intern's previous experience and confidence. Educational strategies were developed. Learner knowledge was assessed before and after modules, deficiencies identified enabled employment of active learning strategies. Modular and curricular evaluations were completed.

RESULTS

TNA determined all interns had been taught knot tying and suturing, and were most confident with suturing, knot tying, and urethral catheterization. Educational strategies included simulation and lectures. Evaluations demonstrated improvement in test scores (pre-v post-) and skills confidence on curricula completion.

CONCLUSION

Our framework utilizes institutional resources and expertise while focusing on determining existing knowledge, skill, and technical deficiencies of learners. This approach demonstrated improvement in knowledge and confidence, and could improve implementation rates of the Phase 1 curriculum.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): a prospective comparative single center study

BACKGROUND

Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).

METHODS

All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire.

RESULTS

A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.

CONCLUSION

While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

Short-term outcome after robot-assisted hiatal hernia and anti-reflux surgery-is there a benefit for the patient?

PURPOSE

The robotic system was introduced to overcome the technical limitations of conventional laparoscopy. For complex oncological operations, it appears to offer further advantages. With regard to hiatal hernia repair, its role has yet to be determined.

METHODS

All consecutive patients who received elective laparoscopic or robot-assisted hiatal hernia repair at a single institution between January 2016 and July 2020 were retrospectively evaluated. We compared both techniques with particular focus on their short-term outcome. A propensity score-matched comparison considering clinical and surgical covariates was also performed between the two groups.

RESULTS

140 patients were included, and 55 (39.3%) underwent a robot-assisted procedure. The baseline demographics and the frequency of previous abdominal operations were comparable for both groups. The size of the hiatal hernia did not differ significantly between the groups (p = 0.06). The mean operative time was significantly longer for the robot-assisted procedure (149 vs. 125 min; p < 0.01) but decreased markedly during the study period. By contrast, no significant differences were observed in terms of conversion rate (p = 1.0) and blood loss (p = 0.25). Likewise, the postoperative morbidity was comparable for both groups (10.9 vs. 12.9; p = 0.79). The hospital length of stay was not significantly different between the laparoscopic and robotic group (4.0 vs. 3.6 days; p = 0.2). After propensity score-matching, 48 patients were identified for each group. Except for the operative time, no other significant differences were found. Thus, the results of the univariate analysis were confirmed.

CONCLUSION

Our initial results failed to demonstrate a clear advantage of the robotic technique in patients with refractory gastroesophageal reflux disease and/or symptomatic hiatal hernias.

Robotic Versus Laparoscopic Approach to Hiatal Hernia Repair: Results After 7 Years of Robotic Experience

INTRODUCTION

Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs.

METHODS

A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software.

RESULTS

Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001).

DISCUSSION

Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.