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Zhuang Y, Tang X, Wu W, Pan W, Wang J. Comparison of da Vinci Robot-Assisted and Conventional Laparoscopic Surgery for Hiatal Hernia in Children after Repair for Esophageal Atresia. J Laparoendosc Adv Surg Tech A 2025. [PMID: 40097235 DOI: 10.1089/lap.2024.0357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2025] Open
Abstract
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.
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Affiliation(s)
- Yujia Zhuang
- Department of Pediatric Surgery, Shanghai Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyu Tang
- Department of Pediatric Surgery, Shanghai Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenjie Wu
- Department of Pediatric Surgery, Shanghai Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weihua Pan
- Department of Pediatric Surgery, Shanghai Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Wang
- Department of Pediatric Surgery, Shanghai Xinhua Hospital, Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Pediatric Surgery, Hangzhou Children's Hospital, Hangzhou, China
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Dosch M, Chevallay M, Jung MK, Mönig S. Voluminous hiatal hernias - the role of robotic surgery. Innov Surg Sci 2025; 10:43-49. [PMID: 40144781 PMCID: PMC11934938 DOI: 10.1515/iss-2023-0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/01/2024] [Indexed: 03/28/2025] Open
Abstract
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.
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Affiliation(s)
- Michel Dosch
- Surgery Department, The Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Mickael Chevallay
- Surgery Department, The Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Minoa K. Jung
- Surgery Department, The Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
| | - Stefan Mönig
- Surgery Department, The Division of Digestive Surgery, University Hospitals of Geneva, Geneva, Switzerland
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McClinton A, Zarnegar R, Dakin G, Afaneh C. Hiatal Hernia Repair: A Century Between Soresi and da Vinci. Surg Clin North Am 2025; 105:125-142. [PMID: 39523068 DOI: 10.1016/j.suc.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
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.
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Affiliation(s)
- Aneesah McClinton
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, Box 294, New York, NY 10065, USA
| | - Rasa Zarnegar
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, Box 294, New York, NY 10065, USA
| | - Gregory Dakin
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, Box 294, New York, NY 10065, USA
| | - Cheguevara Afaneh
- Department of Surgery, Weill Cornell Medicine, 525 East 68th Street, Box 294, New York, NY 10065, USA.
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Siow SL, Ong ECW. Quality of Life Following Laparoscopic Hiatal Hernia Repair and Anterior 180° Partial Fundoplication for Symptomatic Sliding Hiatal Hernia. Asian J Endosc Surg 2025; 18:e70074. [PMID: 40344382 DOI: 10.1111/ases.70074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2025] [Revised: 03/30/2025] [Accepted: 04/20/2025] [Indexed: 05/11/2025]
Abstract
BACKGROUND Laparoscopic hiatal hernia repair (LHHR) is the treatment of choice for symptomatic sliding hiatal hernia. This study evaluates health-related quality of life (HRQOL) outcomes following LHHR with anterior 180° partial fundoplication. METHODS Forty consecutive patients underwent LHHR with anterior 180° partial fundoplication between June 2020 and December 2022. Patients were included based on one of the following criteria: persistent symptoms despite optimal medical therapy (55%), preference for a surgical solution over lifelong medication (37.5%), or complications including reflux oesophagitis/Barrett's esophagus (7.5%). HRQOL was assessed using the SF-36 questionnaire preoperatively and at 1, 6, and 12 months postoperatively. RESULTS Significant improvements were observed in physical functioning (66.3 ± 24.7 to 95.6 ± 7.7, p < 0.001), bodily pain (38.1 ± 28.1 to 79.2 ± 18.6, p < 0.001), general health (37.7 ± 16.2 to 66.1 ± 23.6, p < 0.001), social function (62.5 ± 23.7 to 85.6 ± 16.1, p < 0.001), and mental health (68.2 ± 21.4 to 83.7 ± 12.5, p < 0.001) at 12 months. Role limitations due to physical health improved gradually, becoming significant at 12 months (60.0 ± 45.6 to 86.9 ± 16.8, p < 0.001). Early improvements in vitality (p = 0.02) and role limitations due to emotional health (p = 0.331) showed some decline by 12 months. The median hospital stay was 3 days, with no major complications. At 1 year, 72.5% of patients were medication-free, while anatomical recurrence was observed in 7.5%. Patients with recurrence showed lower physical functioning (82.3 vs. 96.8, p = 0.02) and bodily pain scores (65.7 vs. 80.5, p = 0.04) but still demonstrated significant improvement from baseline. Body mass index, education level, age, and defect area did not influence outcomes (all p > 0.05). CONCLUSION LHHR with anterior 180° partial fundoplication significantly improves quality of life across multiple domains, with sustained benefits at 12 months post-surgery, particularly in physical function, pain, and social functioning. Most domains reached or surpassed population norms by 12 months, establishing this approach as an effective treatment for symptomatic sliding hiatal hernia.
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Affiliation(s)
- Sze Li Siow
- Department of General Surgery, Hospital Umum Sarawak, Ministry of Health Malaysia, Kuching, Malaysia
- Department of Surgery, Taylor's University School of Medicine, Subang Jaya, Malaysia
- Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Ernest Cun Wang Ong
- Department of General Surgery, National Cancer Institute, Ministry of Health Malaysia, Putrajaya, Malaysia
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Bauerle W, Franey D, Allsbrook A, Evans J, Reese V, Stoltzfus J, Harrison M, Burfeind W, Brown AM. Retrospective cost analysis of robotic and laparoscopic anti-reflux surgery and paraesophageal hernia repair. Surg Endosc 2024:10.1007/s00464-024-11294-9. [PMID: 39367133 DOI: 10.1007/s00464-024-11294-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 09/13/2024] [Indexed: 10/06/2024]
Abstract
INTRODUCTION Increased adoption of robotics in foregut surgery evokes questions regarding efficacy, safety, and cost. To many, cost remains a barrier to adoption of a robotic approach. The authors' aim to determine the difference in cost of a robotic (R-) vs laparoscopic (L-) approach for paraesophageal hernia repair (PEHR). METHODS Patients 18 years and older who underwent PEHR between July 2016 and June 2021 at a university health network were included. Variables of interest included 30 day outcomes, 1 year recurrence rates, and several cost variables including hospital length of stay, operating room (OR) time, chargeable supplies and implants, non-chargeable supplies, and indirect cost. Cost data were stratified by type and the presence of fundoplication, as well as the elective versus urgent nature of the procedures. Statistical analysis consisted of parametric and non-parametric analyses, with p < 0.05 denoting statistical significance. RESULTS 405 patients were included in the study (n = 188 for R-, n = 217 for L-). Significant differences were observed in the type of anti-reflux procedure performed (p < 0.001), use of mesh (R- 70.2% vs. L- 59.0%, p = 0.019), and whether a Collis gastroplasty was performed (R- 4.3% vs. L- 10.2%, p = 0.023). No differences in 30-day readmission or reoperation rates, Clavien-Dindo complication rates, or 1-year hernia recurrence rates were observed. For elective cases, regardless of the type of anti-reflux procedure performed, a robotic approach was associated with a significantly greater cost (p < 0.002). Comparing all procedures, a statistically significant increase in cost was seen with a robotic approach (R- $29,706.88 vs. L- $23,457.07, p < 0.001). CONCLUSIONS Complication rates and surgical outcomes between the two approaches were similar; however, cost is significantly increased when a robotic approach is utilized. Future studies are needed to delineate which drivers of cost are modifiable with the robot.
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Affiliation(s)
- Wayne Bauerle
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Daniel Franey
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Anthony Allsbrook
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Joseph Evans
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Vanessa Reese
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Jill Stoltzfus
- Department of Research and Innovation, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Meredith Harrison
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - William Burfeind
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA
| | - Andrew M Brown
- Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA.
- , 701 Ostrum St. Suite 202, Bethlehem, PA, 18015, USA.
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Powell C, DeGregorio A, Bews K, Wigle D, Habermann E. Perioperative outcomes of robotic versus laparoscopic paraesophageal hernia repair: a NSQIP analysis. Surg Endosc 2024; 38:5851-5857. [PMID: 39160316 DOI: 10.1007/s00464-024-11158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 08/04/2024] [Indexed: 08/21/2024]
Abstract
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.
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Affiliation(s)
- Chelsea Powell
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | | | - Katie Bews
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Dennis Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Ceccarelli G, Catena F, Avella P, Tian BW, Rondelli F, Guerra G, De Rosa M, Rocca A. Emergency robotic surgery: the experience of a single center and review of the literature. World J Emerg Surg 2024; 19:28. [PMID: 39154016 PMCID: PMC11330055 DOI: 10.1186/s13017-024-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 07/22/2024] [Indexed: 08/19/2024] Open
Abstract
BACKGROUNDS Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review. METHODS We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases). RESULTS 36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%. CONCLUSIONS Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.
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Affiliation(s)
- Graziano Ceccarelli
- Department of General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Fausto Catena
- Division of General Surgery, Bufalini Hospital, Cesena, Italy
| | - Pasquale Avella
- Department of General Surgery and Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy.
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy.
| | - Brian Wca Tian
- Department of General Surgery, Singapore General Hospital, Singapore, Singapore
| | - Fabio Rondelli
- Department of General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Germano Guerra
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
| | - Michele De Rosa
- Department of General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Foligno, Perugia, Italy
| | - Aldo Rocca
- Department of General Surgery and Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
- Department of Medicine and Health Science "V. Tiberio", University of Molise, Campobasso, Italy
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Awshah S, Mhaskar R, Diab ARF, Read M, Coughlin E, Ganam S, Saad AR, Sujka J, DuCoin C. Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy. J Am Coll Surg 2024; 239:171-186. [PMID: 38497555 DOI: 10.1097/xcs.0000000000001074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
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.
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Affiliation(s)
- Sabrina Awshah
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
| | - Rahul Mhaskar
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
| | - Abdul-Rahman Fadi Diab
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Meagan Read
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Emily Coughlin
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
| | - Samer Ganam
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Adham R Saad
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Joseph Sujka
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Christopher DuCoin
- From the Morsani College of Medicine, University of South Florida, Tampa, FL (Awshah, Mhaskar, Coughlin, Saad, Sujka, DuCoin)
- Departments of Medical Education (Mhaskar, Coughlin) and Surgery (Diab, Read, Ganam, Saad, Sujka, DuCoin), Morsani College of Medicine, University of South Florida, Tampa, FL
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Holland AM, Lorenz WR, Cavanagh JC, Smart NJ, Ayuso SA, Scarola GT, Kercher KW, Jorgensen LN, Janis JE, Fischer JP, Heniford BT. Comparison of Medical Research Abstracts Written by Surgical Trainees and Senior Surgeons or Generated by Large Language Models. JAMA Netw Open 2024; 7:e2425373. [PMID: 39093561 PMCID: PMC11297395 DOI: 10.1001/jamanetworkopen.2024.25373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 06/04/2024] [Indexed: 08/04/2024] Open
Abstract
Importance Artificial intelligence (AI) has permeated academia, especially OpenAI Chat Generative Pretrained Transformer (ChatGPT), a large language model. However, little has been reported on its use in medical research. Objective To assess a chatbot's capability to generate and grade medical research abstracts. Design, Setting, and Participants In this cross-sectional study, ChatGPT versions 3.5 and 4.0 (referred to as chatbot 1 and chatbot 2) were coached to generate 10 abstracts by providing background literature, prompts, analyzed data for each topic, and 10 previously presented, unassociated abstracts to serve as models. The study was conducted between August 2023 and February 2024 (including data analysis). Exposure Abstract versions utilizing the same topic and data were written by a surgical trainee or a senior physician or generated by chatbot 1 and chatbot 2 for comparison. The 10 training abstracts were written by 8 surgical residents or fellows, edited by the same senior surgeon, at a high-volume hospital in the Southeastern US with an emphasis on outcomes-based research. Abstract comparison was then based on 10 abstracts written by 5 surgical trainees within the first 6 months of their research year, edited by the same senior author. Main Outcomes and Measures The primary outcome measurements were the abstract grades using 10- and 20-point scales and ranks (first to fourth). Abstract versions by chatbot 1, chatbot 2, junior residents, and the senior author were compared and judged by blinded surgeon-reviewers as well as both chatbot models. Five academic attending surgeons from Denmark, the UK, and the US, with extensive experience in surgical organizations, research, and abstract evaluation served as reviewers. Results Surgeon-reviewers were unable to differentiate between abstract versions. Each reviewer ranked an AI-generated version first at least once. Abstracts demonstrated no difference in their median (IQR) 10-point scores (resident, 7.0 [6.0-8.0]; senior author, 7.0 [6.0-8.0]; chatbot 1, 7.0 [6.0-8.0]; chatbot 2, 7.0 [6.0-8.0]; P = .61), 20-point scores (resident, 14.0 [12.0-7.0]; senior author, 15.0 [13.0-17.0]; chatbot 1, 14.0 [12.0-16.0]; chatbot 2, 14.0 [13.0-16.0]; P = .50), or rank (resident, 3.0 [1.0-4.0]; senior author, 2.0 [1.0-4.0]; chatbot 1, 3.0 [2.0-4.0]; chatbot 2, 2.0 [1.0-3.0]; P = .14). The abstract grades given by chatbot 1 were comparable to the surgeon-reviewers' grades. However, chatbot 2 graded more favorably than the surgeon-reviewers and chatbot 1. Median (IQR) chatbot 2-reviewer grades were higher than surgeon-reviewer grades of all 4 abstract versions (resident, 14.0 [12.0-17.0] vs 16.9 [16.0-17.5]; P = .02; senior author, 15.0 [13.0-17.0] vs 17.0 [16.5-18.0]; P = .03; chatbot 1, 14.0 [12.0-16.0] vs 17.8 [17.5-18.5]; P = .002; chatbot 2, 14.0 [13.0-16.0] vs 16.8 [14.5-18.0]; P = .04). When comparing the grades of the 2 chatbots, chatbot 2 gave higher median (IQR) grades for abstracts than chatbot 1 (resident, 14.0 [13.0-15.0] vs 16.9 [16.0-17.5]; P = .003; senior author, 13.5 [13.0-15.5] vs 17.0 [16.5-18.0]; P = .004; chatbot 1, 14.5 [13.0-15.0] vs 17.8 [17.5-18.5]; P = .003; chatbot 2, 14.0 [13.0-15.0] vs 16.8 [14.5-18.0]; P = .01). Conclusions and Relevance In this cross-sectional study, trained chatbots generated convincing medical abstracts, undifferentiable from resident or senior author drafts. Chatbot 1 graded abstracts similarly to surgeon-reviewers, while chatbot 2 was less stringent. These findings may assist surgeon-scientists in successfully implementing AI in medical research.
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Affiliation(s)
- Alexis M. Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - William R. Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Jack C. Cavanagh
- Department of Economics, Massachusetts Institute of Technology, Cambridge
| | - Neil J. Smart
- Division of Colorectal Surgery, Department of Surgery, Royal Devon & Exeter Hospital, Exeter, Devon, United Kingdom
| | - Sullivan A. Ayuso
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Gregory T. Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Kent W. Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Lars N. Jorgensen
- Department of Clinical Medicine, University of Copenhagen, Bispedjerg & Frederiksberg Hospital, Copenhagen, Denmark
| | - Jeffrey E. Janis
- Division of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus
| | - John P. Fischer
- Division of Plastic Surgery, University of Pennsylvania Health System, Philadelphia
| | - B. Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
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10
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Gonçalves-Costa D, Barbosa JP, Quesado R, Lopes V, Barbosa J. Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis. Langenbecks Arch Surg 2024; 409:175. [PMID: 38842610 PMCID: PMC11156741 DOI: 10.1007/s00423-024-03368-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/26/2024] [Indexed: 06/07/2024]
Abstract
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.
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Affiliation(s)
- Diogo Gonçalves-Costa
- Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.
| | - José Pedro Barbosa
- MEDCIDS - Department of Community Medicine, Information and Decision in Health, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Stomatology, São João University Hospital Center, Porto, Portugal
| | - Rodrigo Quesado
- Faculty of Medicine, University of Porto, Al. Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Vítor Lopes
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
| | - José Barbosa
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of General Surgery, São João University Hospital Center, Porto, Portugal
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11
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DeMeester SR, Bernard L, Schoppmann SF, McKay SC, Roth JS. Updated Markov Model to Determine Optimal Management Strategy for Patients with Paraesophageal Hernia and Symptoms, Cameron Ulcer, or Comorbid Conditions. J Am Coll Surg 2024; 238:1069-1082. [PMID: 38359322 DOI: 10.1097/xcs.0000000000001040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
BACKGROUND The current paradigm of watchful waiting (WW) in people 65 years or older with an asymptomatic paraesophageal hernia (PEH) is based on a now 20-year-old Markov analysis. Recently, we have shown that elective laparoscopic hernia repair (ELHR) provides an increase in life-years (L-Ys) compared with WW in most healthy patients aged 40 to 90 years. However, elderly patients often have comorbid conditions and may have complications from their PEH such as Cameron lesions. The aim of this study was to determine the optimal strategy, ELHR or WW, in these patients. STUDY DESIGN A Markov model with updated variables was used to compare L-Ys gained with ELHR vs WW in hypothetical people with any type of PEH and symptoms, Cameron lesions, and/or comorbid conditions. RESULTS In men and women aged 40 to 90 years with PEH-related symptoms and/or Cameron lesions, ELHR led to an increase in L-Ys over WW. The presence of comorbid conditions impacted life expectancy overall, but ELHR remained the preferred approach in all but 90-year-old patients with symptoms but no Cameron lesions. CONCLUSIONS Using a Markov model with updated values for key variables associated with management options for patients with a PEH, we showed that life expectancy was improved with ELHR in most men and women aged 40 to 90 years, particularly in the presence of symptoms and/or Cameron lesions. Comorbid conditions increase the risk for surgery, but ELHR remained the preferred strategy in the majority of symptomatic patients. This model can be used to provide individualized management guidance for patients with a PEH.
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Affiliation(s)
- Steven R DeMeester
- From the Center for Advanced Surgery, The Oregon Clinic, Portland, OR (DeMeester)
| | - Lisa Bernard
- Bernard Consulting, Selkirk, Ontario, Canada (Bernard)
| | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY (Roth)
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12
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Lunardi N, Abou-Zamzam A, Florecki KL, Chidambaram S, Shih IF, Kent AJ, Joseph B, Byrne JP, Sakran JV. Robotic Technology in Emergency General Surgery Cases in the Era of Minimally Invasive Surgery. JAMA Surg 2024; 159:493-499. [PMID: 38446451 PMCID: PMC10918578 DOI: 10.1001/jamasurg.2024.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 12/03/2023] [Indexed: 03/07/2024]
Abstract
Importance Although robotic surgery has become an established approach for a wide range of elective operations, data on its utility and outcomes are limited in the setting of emergency general surgery. Objectives To describe temporal trends in the use of laparoscopic and robotic approaches and compare outcomes between robotic and laparoscopic surgery for 4 common emergent surgical procedures. Design, Setting, and Participants A retrospective cohort study of an all-payer discharge database of 829 US facilities was conducted from calendar years 2013 to 2021. Data analysis was performed from July 2022 to November 2023. A total of 1 067 263 emergent or urgent cholecystectomies (n = 793 800), colectomies (n = 89 098), inguinal hernia repairs (n = 65 039), and ventral hernia repairs (n = 119 326) in patients aged 18 years or older were included. Exposure Surgical approach (robotic, laparoscopic, or open) to emergent or urgent cholecystectomy, colectomy, inguinal hernia repair, or ventral hernia repair. Main Outcomes and Measures The primary outcome was the temporal trend in use of each operative approach (laparoscopic, robotic, or open). Secondary outcomes included conversion to open surgery and length of stay (both total and postoperative). Temporal trends were measured using linear regression. Propensity score matching was used to compare secondary outcomes between robotic and laparoscopic surgery groups. Results During the study period, the use of robotic surgery increased significantly year-over-year for all procedures: 0.7% for cholecystectomy, 0.9% for colectomy, 1.9% for inguinal hernia repair, and 1.1% for ventral hernia repair. There was a corresponding decrease in the open surgical approach for all cases. Compared with laparoscopy, robotic surgery was associated with a significantly lower risk of conversion to open surgery: cholecystectomy, 1.7% vs 3.0% (odds ratio [OR], 0.55 [95% CI, 0.49-0.62]); colectomy, 11.2% vs 25.5% (OR, 0.37 [95% CI, 0.32-0.42]); inguinal hernia repair, 2.4% vs 10.7% (OR, 0.21 [95% CI, 0.16-0.26]); and ventral hernia repair, 3.5% vs 10.9% (OR, 0.30 [95% CI, 0.25-0.36]). Robotic surgery was associated with shorter postoperative lengths of stay for colectomy (-0.48 [95% CI, -0.60 to -0.35] days), inguinal hernia repair (-0.20 [95% CI, -0.30 to -0.10] days), and ventral hernia repair (-0.16 [95% CI, -0.26 to -0.06] days). Conclusions and Relevance While robotic surgery is still not broadly used for emergency general surgery, the findings of this study suggest it is becoming more prevalent and may be associated with better outcomes as measured by reduced conversion to open surgery and decreased length of stay.
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Affiliation(s)
- Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas
| | - Aida Abou-Zamzam
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - I-Fan Shih
- Global Access Value Economics, Intuitive Surgical, Sunnyvale, California
| | - Alistair J. Kent
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson
| | - James P. Byrne
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph V. Sakran
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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13
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Hershkovitz Y, Ben Yehuda A, Dykman D, Jeroukhimov I. Urgent Paraesophageal Hernia: Can We Do Better? J Laparoendosc Adv Surg Tech A 2024; 34:235-238. [PMID: 38010270 DOI: 10.1089/lap.2023.0421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023] Open
Abstract
Introduction: Paraesophageal hernia (PEH) is a relatively common pathology in the Western population. It may be asymptomatic, but ∼50% of patients with PEH have symptoms that may mimic gastrointestinal, respiratory, and cardiac pathology. Surgery is recommended in all acute cases of PEH, but indications for surgical intervention in asymptomatic or nonacutely symptomatic patient remain unclear. Purpose of this study was to evaluate our experience in management of patients with PEH admitted to the surgical word. Our special interest was in acute cases of emergency admission who were previously discharged from emergency room (ER). Methods: Data of patients who underwent PEH repair from January 1, 2017 to May, 2023, were retrospectively evaluated. Patients were divided into two groups. Group I included patients admitted through ER with acute symptoms of PEH. Patients who underwent elective surgery were included in group II. Group I patients were additionally divided on those who previously visited ER, and signs of PEH were underscored and those who were admitted to ER first time. Results: Ninety-eight patients underwent laparoscopic PEH repair. Group I included 28 patients (28.9%). Significant differences were noticed in patient's age, main complaint, and rate of complications. Fourteen patients from group I were previously discharged from ER, and in 12 of them, imaging study clearly showed diaphragmatic hernia. Conclusion: Patients who underwent elective laparoscopic PEH repair have better outcome. Signs of PEH may be underscored by ER physicians. Higher index of suspicion required to diagnose this relatively rare reason of ER admission.
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Affiliation(s)
- Yehuda Hershkovitz
- Trauma Unit, Shamir Medical Center Affiliated with University Tel Aviv, Zerefin, Israel
| | - Amir Ben Yehuda
- Division of Surgery, Shamir Medical Center Affiliated with University Tel Aviv, Zerefin, Israel
| | - Daniel Dykman
- Trauma Unit, Shamir Medical Center Affiliated with University Tel Aviv, Zerefin, Israel
| | - Igor Jeroukhimov
- Trauma Unit, Shamir Medical Center Affiliated with University Tel Aviv, Zerefin, Israel
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14
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Brandalise A, Herbella FAM, Luna RA, Szachnowicz S, Sallum RAA, Domene CE, Volpe P, Cavazzolla LT, Furtado ML, Claus CMP, Farah JFDM, Crema E. BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2024; 36:e1787. [PMID: 38324849 PMCID: PMC10841492 DOI: 10.1590/0102-672020230069e1787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 10/21/2023] [Indexed: 02/09/2024]
Abstract
Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.
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Affiliation(s)
- André Brandalise
- Centro Médico de Campinas, Robotic Surgery Program - Campinas (SP), Brazil
| | | | - Renato Abrantes Luna
- Universidade Federal do Estado do Rio de Janeiro, Faculty of Medicine and Surgery, Hospital Federal dos Servidores do Estado - Rio de Janeiro (RJ), Brazil
| | - Sergio Szachnowicz
- Universidade de São Paulo, Department of Gastroenterology - São Paulo (SP), Brazil
| | | | | | - Paula Volpe
- Centro Integrado de Medicina Avançada - São Paulo (SP), Brazil
| | - Leandro Totti Cavazzolla
- Universidade Federal do Rio Grande do Sul, University Hospital, General Surgery Unit - Porto Alegre (RS), Brazil
| | - Marcelo Lopes Furtado
- Sociedade Brasileira de Hérna e Parede Abdominal, Hospital Pintagueiras, Videolaparoscopic Surgery Service - Jundiaí, São Paulo (SP), Brazil
| | - Christiano Marlo Paggi Claus
- Universidade Positivo, Postgraduate Program in Minimally Invasive Surgery, Department of Surgical Clinic - Curitiba (PR), Brazil
| | | | - Eduardo Crema
- Universidade Federal do Triângulo Mineiro, Digestive Surgical Unit - Uberaba (MG), Brazil
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15
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DeMeester SR, Bernard L, Schoppmann SF, Kloosterman R, Roth JS. Elective Laparoscopic Paraesophageal Hernia Repair Leads to an Increase in Life Expectancy Over Watchful Waiting in Asymptomatic Patients: An Updated Markov Analysis. Ann Surg 2024; 279:267-275. [PMID: 37818675 DOI: 10.1097/sla.0000000000006119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
OBJECTIVE The aim of this study was to perform an updated Markov analysis to determine the optimal management strategy for patients with an asymptomatic paraesophageal hernia (PEH): elective laparoscopic hernia repair (ELHR) versus watchful waiting (WW). BACKGROUND Currently, it is recommended that patients with an asymptomatic PEH not undergo repair based on a 20-year-old Markov analysis. The current recommendation might lead to preventable hospitalizations for acute PEH-related complications and compromised survival. METHODS A Markov model with updated variables was used to compare life-years (L-Ys) gained with ELHR versus WW in patients with a PEH. One-way sensitivity analyses evaluated the robustness of the analysis to alternative data inputs, while probabilistic sensitivity analysis quantified the level of confidence in the results in relation to the uncertainty across all model inputs. RESULTS At age 40 to 90, ELHR led to greater life expectancy than WW, particularly in women. The gain in L-Ys (2.6) was greatest in a 40-year-old woman and diminished with increasing age. Sensitivity analysis showed that alternative values resulted in modest changes in the difference in L-Ys, but ELHR remained the preferred strategy. Probabilistic analysis showed that ELHR was the preferred strategy in 100% of 10,000 simulations for age 65, 98% for age 80, 90% for age 85, and 59% of simulations in 90-year-old women. CONCLUSIONS This updated analysis showed that ELHR leads to an increase in L-Ys over WW in healthy patients aged 40 to 90 years with an asymptomatic PEH. In this new paradigm, all patients with a PEH, regardless of symptoms, should be referred for the consideration of elective repair to maximize their life expectancy.
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Affiliation(s)
| | | | | | | | - J Scott Roth
- Department of Surgery, The University of Kentucky, Lexington, KY
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16
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Gao Y, Han X, Tan Z. Evaluation of robot-assisted laparoscopic versus conventional laparoscopic hiatal hernia repair in children. J Robot Surg 2024; 18:32. [PMID: 38231355 DOI: 10.1007/s11701-023-01805-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/19/2023] [Indexed: 01/18/2024]
Abstract
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.
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Affiliation(s)
- Yue Gao
- Department of Paediatric Thoracic Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, China
| | - Xu Han
- Department of Clinical Laboratory, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang, China
| | - Zheng Tan
- Department of Paediatric Thoracic Surgery, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, 310052, Zhejiang, China.
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17
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Giulini L, Razia D, Latorre-Rodríguez AR, Shacker M, Csucska M, Mittal SK. Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center. J Gastrointest Surg 2023; 27:2308-2315. [PMID: 37715012 DOI: 10.1007/s11605-023-05829-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/31/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. METHODS After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. RESULTS A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 ± 11.0, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 ± 3.2 vs 1.4 ± 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 ± 25.0 and 43.5 ± 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 ± 10.9 vs L/G-HH: 7.1 ± 11.3; p = 0.63). There was no perioperative mortality. CONCLUSIONS HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.
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Affiliation(s)
- Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Department of General, Gastrointestinal and Thoracic Surgery, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Mark Shacker
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Mate Csucska
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ, 85013, USA.
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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18
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Ma L, Luo H, Kou S, Gao Z, Bai D, Qin X, Ouchi T, Gong L, Hu J, Tian Y. Robotic versus laparoscopic surgery for hiatal hernia repair: a systematic literature review and meta-analysis. J Robot Surg 2023; 17:1879-1890. [PMID: 37247119 DOI: 10.1007/s11701-023-01636-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
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.
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Affiliation(s)
- Longyin Ma
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Heng Luo
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Shien Kou
- School of Medical Clinical, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Zhenguo Gao
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Dan Bai
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Xiangzhi Qin
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Takahiro Ouchi
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Lei Gong
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China
| | - Jiani Hu
- Department of Radiology, Wayne State University, Detroit, MI, 48201, USA
| | - Yunhong Tian
- Department of General Surgery, The Affiliated Nanchong Central Hospital of North Sichuan Medical College (University), Nanchong, 637000, Sichuan, China.
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19
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Elissavet S, Ioannis G, Panagiotis P, Konstantinos M, Apostolos K. Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis. JOURNAL OF MINIMALLY INVASIVE SURGERY 2023; 26:134-145. [PMID: 37712313 PMCID: PMC10505365 DOI: 10.7602/jmis.2023.26.3.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/15/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
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.
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Affiliation(s)
- Symeonidou Elissavet
- 5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Gkoutziotis Ioannis
- 5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Petras Panagiotis
- 5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Mpallas Konstantinos
- 5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kamparoudis Apostolos
- 5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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20
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Panse NS, Prasath V, Quinn PL, Chokshi RJ. Economic evaluation of robotic and laparoscopic paraesophageal hernia repair. Surg Endosc 2023; 37:6806-6817. [PMID: 37264228 DOI: 10.1007/s00464-023-10119-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/08/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Neal S Panse
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Vishnu Prasath
- Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Patrick L Quinn
- Department of Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA
| | - Ravi J Chokshi
- Division of Surgical Oncology, Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Newark, NJ, 07103, USA.
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21
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Wang TN, An BW, Wang TX, Tamer R, Yuce TK, Hassanein RT, Haisley KR, Perry KA, Sweigert PJ. Assessing the effects of smoking status on outcomes of elective minimally invasive paraesophageal hernia repair. Surg Endosc 2023; 37:7238-7246. [PMID: 37400691 DOI: 10.1007/s00464-023-10185-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 05/30/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Patients are often advised on smoking cessation prior to elective surgical interventions, but the impact of active smoking on paraesophageal hernia repair (PEHR) outcomes is unclear. The objective of this cohort study was to evaluate the impact of active smoking on short-term outcomes following PEHR. METHODS Patients who underwent elective PEHR at an academic institution between 2011 and 2022 were retrospectively reviewed. The National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2021 was queried for PEHR. Patient demographics, comorbidities, and 30-day post-operative data were collected and maintained in an IRB-approved database. Cohorts were stratified by active smoking status. Primary outcomes included rates of death or serious morbidity (DSM) and radiographically identified recurrence. Bivariate and multivariable regressions were performed, and p value < 0.05 was considered statistically significant. RESULTS 538 patients underwent elective PEHR in the single-institution cohort, of whom 5.8% (n = 31) were smokers. 77.7% (n = 394) were female, median age was 67 [IQR 59, 74] years, and median follow-up was 25.3 [IQR 3.2, 53.6] months. Rates of DSM (non-smoker 4.5% vs smoker 6.5%, p = 0.62) and hernia recurrence (33.3% vs 48.4%, p = 0.09) did not differ significantly. On multivariable analysis, smoking status was not associated with any outcome (p > 0.2). On NSQIP analysis, 38,284 PEHRs were identified, of whom 8.6% (n = 3584) were smokers. Increased DSM was observed among smokers (non-smoker 5.1%, smoker 6.2%, p = 0.004). Smoking status was independently associated with increased risk of DSM (OR 1.36, p < 0.001), respiratory complications (OR 1.94, p < 0.001), 30-day readmission (OR 1.21, p = 0.01), and discharge to higher level of care (OR 1.59, p = 0.01). No difference was seen in 30-day mortality or wound complications. CONCLUSION Smoking status confers a small increased risk of short-term morbidity following elective PEHR without increased risk of mortality or hernia recurrence. While smoking cessation should be encouraged for all active smokers, minimally invasive PEHR in symptomatic patients should not be delayed on account of patient smoking status.
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Affiliation(s)
- Theresa N Wang
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA.
| | - Bryan W An
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Tina X Wang
- College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Robert Tamer
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
| | - Tarik K Yuce
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
| | - Roukaya T Hassanein
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
| | - Kelly R Haisley
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
| | - Kyle A Perry
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
| | - Patrick J Sweigert
- Center for Minimally Invasive Surgery, The Ohio State University, 395 W 12th Ave Suite 670, Columbus, OH, 43210, USA
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22
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Chervu N, Mabeza RM, Kronen E, Sakowitz S, Bakhtiyar SS, Hadaya J, Benharash P. Contemporary association of preoperative malnutrition and outcomes of hiatal hernia repairs in the United States. Surgery 2023:S0039-6060(23)00188-5. [PMID: 37217387 DOI: 10.1016/j.surg.2023.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/05/2023] [Accepted: 04/09/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Hypoalbuminemia has been used as a surrogate for malnutrition and is associated with worse postoperative outcomes across major operations. Because patients with hiatal hernia often have inadequate caloric intake, we examined the association of serum albumin levels with outcomes after hiatal hernia repair. METHODS Adults undergoing elective and non-elective hiatal hernia repair via any approach were tabulated from the 2012 to 2019 National Surgical Quality Improvement Program. Patients were stratified into the Hypoalbuminemia cohort if serum albumin <3.5 mg/dL using restricted cubic spline analysis. Major adverse events were defined as a composite of all-cause mortality and major complications per the American College of Surgeons National Surgical Quality Improvement Program risk calculator. Entropy balancing was used to adjust for intergroup differences. Multivariable regression models were then constructed to assess the association of preoperative albumin with major adverse events, postoperative length of stay, and 30-day readmission. RESULTS Of 23,103 patients, 11.7% comprised the Hypoalbuminemia cohort. The Hypoalbuminemia group was older, less commonly of White race, and less likely to have an independent functional status than others. They were also more likely to undergo inpatient, non-elective surgery via laparotomy. After entropy balancing and adjustment, hypoalbuminemia remained associated with increased odds of major adverse events and multiple complications and longer adjusted postoperative length of stay. There was no significant difference in adjusted odds of readmission. CONCLUSION We used a quantitative methodology to establish a serum albumin threshold of 3.5 mg/dL associated with increased adjusted odds of major adverse events, increased postoperative length of stay, and postoperative complications after hiatal hernia repair. These results may guide preoperative nutrition supplementation.
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Affiliation(s)
- Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; Depatment of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Russyan Mark Mabeza
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; Department of Surgery, University of Colorado, Aurora, CO
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; Depatment of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, CA; Depatment of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA.
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23
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Collins ML, Mack SJ, Till BM, Whitehorn GL, Tofani C, Chojnacki K, Grenda T, Evans NR, Okusanya OT. Defining risk factors for mortality after emergent hiatal hernia repair in the era of minimally invasive surgery. Am J Surg 2023; 225:1056-1061. [PMID: 36653267 DOI: 10.1016/j.amjsurg.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/06/2022] [Accepted: 01/09/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND Risk factors for mortality following emergent hiatal hernia (HH) repair in the era of minimally invasive surgery remain poorly defined. METHODS Data was obtained from the National Inpatient Sample (NIS), National Readmissions Database, and National Emergency Department Sample for patients undergoing HH repair between 2010 and 2018. Univariate and multivariate logistic regression analyses reported with odds ratio (OR) and 95% confidence intervals (CI) were performed to identify factors associated mortality. RESULTS Via the NIS, mortality rate was 2.2% (147 patients). Via the NEDS, the mortality rate was 3.6% (303 patients). On multivariate analysis, predictors of mortality included age (OR 1.05, CI: 1.04,1.07), male sex (OR 1.49, CI: 1.06,2.11), frailty (OR 2.49, CI: 1.65,3.75), open repair (OR 3.59, CI: 2.50,5.17), and congestive heart failure (OR 2.71, CI: 1.81,4.06). CONCLUSIONS There are multiple risk factors for mortality after hiatal hernia repair. There is merit to a laparoscopic approach even in emergent settings.
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Affiliation(s)
- Micaela L Collins
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA.
| | - Shale J Mack
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Brian M Till
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Gregory L Whitehorn
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Christina Tofani
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Division of Gastroenterology, 132 S 10th St #480, Philadelphia, PA, 19107, USA
| | - Karen Chojnacki
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Minimally Invasive General Surgery, 1015 Walnut St, Curtis Building Suite 620, Philadelphia, PA, 19107, USA
| | - Tyler Grenda
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Nathaniel R Evans
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
| | - Olugbenga T Okusanya
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, Suite 100, Philadelphia, PA, 19107, USA; Thomas Jefferson University Hospital, Department of Surgery, Division of Esophageal and Thoracic Surgery, 211 South 9th St, Suite 300, Philadelphia, PA, 19107, USA
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24
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Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution. Surg Endosc 2023; 37:624-630. [PMID: 35713721 DOI: 10.1007/s00464-022-09359-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 05/16/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Laparoscopic paraesophageal hernia repair (PEHr) is a safe and effective procedure for relieving foregut symptoms associated with paraesophageal hernias (PEH). Nonetheless, it is estimated that about 30-50% of patients will have symptomatic recurrence requiring additional surgical intervention. Revision surgery is technically demanding and may be associated with a higher rate of morbidity and poor patient-reported outcomes. We present the largest study of perioperative and quality-of-life outcomes among patients who underwent laparoscopic revision PEHr. METHODS A retrospective review of all patients who underwent laparoscopic revision paraesophageal hernia repair between February 2003 and October 2019, at a single institution was conducted. All revisions of Type I hiatal hernias were excluded. The following validated surveys were used to evaluate quality-of-life outcomes: Reflux Symptom Index (RSI) and Gastroesophageal Reflux Disease Health-Related QOL (GERD-HRQL). Patient demographic, perioperative, and quality-of-life (QOL) data were analyzed using univariate analysis. RESULTS One hundred ninety patients were included in the final analysis (63.2% female, 90.5% single revision, 9.5% multiple revisions) with a mean age, BMI, and age-adjusted Charlson score of 56.6 ± 14.7 years, 29.7 ± 5.7 kg/m2, and 2.04 ± 1.9, respectively. The study cohort consisted of type II (49.5%), III (46.3%), and IV hiatal hernia (4.2%), respectively. Most patients underwent either a complete (68.7%) or partial (27.7%) fundoplication. A Collis gastroplasty was performed in 14.7% of patients. The median follow-up was 17.6 months. The overall morbidity and mortality rate were 15.8% and 1.1%, respectively. The 30-day readmission rate was 9.5%. Additionally, at latest follow-up 47.9% remained on antireflux medication. At latest follow-up, there was significant improvement in mean RSI score (46.4%, p < 0.001) from baseline within the study population. Furthermore, there was no significant difference in QOL between patients who had a history of an initial repair only or history of revision surgery at latest review. The overall recurrence rate was 16.3% with 6.3% requiring a surgical revision. CONCLUSION Laparoscopic revision PEHr is associated with a low rate of morbidity and mortality. Revision surgery may provide improvement in QOL outcomes, despite the high rate of long-term antireflux medication use. The rate of recurrent paraesophageal hernia remains low with few patients requiring a second revision. However, longer follow-up is needed to better characterize the long-term recurrence rate and symptomatic improvements.
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25
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Reinisch A, Liese J, Padberg W, Ulrich F. Robotic operations in urgent general surgery: a systematic review. J Robot Surg 2022; 17:275-290. [PMID: 35727485 PMCID: PMC10076409 DOI: 10.1007/s11701-022-01425-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 05/06/2022] [Indexed: 12/07/2022]
Abstract
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.
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Affiliation(s)
- Alexander Reinisch
- Department of General, Visceral and Oncologic Surgery, Wetzlar Hospital and Clinics, Forsthausstr. 1, 35578, Wetzlar, Germany.
| | - Juliane Liese
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Giessen, Giessen, Germany
| | - Winfried Padberg
- Department of General, Visceral, Thoracic, Transplant and Pediatric Surgery, University Hospital Giessen, Giessen, Germany
| | - Frank Ulrich
- Department of General, Visceral and Oncologic Surgery, Wetzlar Hospital and Clinics, Forsthausstr. 1, 35578, Wetzlar, Germany
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26
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de’Angelis N, Khan J, Marchegiani F, Bianchi G, Aisoni F, Alberti D, Ansaloni L, Biffl W, Chiara O, Ceccarelli G, Coccolini F, Cicuttin E, D’Hondt M, Di Saverio S, Diana M, De Simone B, Espin-Basany E, Fichtner-Feigl S, Kashuk J, Kouwenhoven E, Leppaniemi A, Beghdadi N, Memeo R, Milone M, Moore E, Peitzmann A, Pessaux P, Pikoulis M, Pisano M, Ris F, Sartelli M, Spinoglio G, Sugrue M, Tan E, Gavriilidis P, Weber D, Kluger Y, Catena F. Robotic surgery in emergency setting: 2021 WSES position paper. World J Emerg Surg 2022; 17:4. [PMID: 35057836 PMCID: PMC8781145 DOI: 10.1186/s13017-022-00410-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/27/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Robotics represents the most technologically advanced approach in minimally invasive surgery (MIS). Its application in general surgery has increased progressively, with some early experience reported in emergency settings. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a systematic review of the literature to develop consensus statements about the potential use of robotics in emergency general surgery. METHODS This position paper was conducted according to the WSES methodology. A steering committee was constituted to draft the position paper according to the literature review. An international expert panel then critically revised the manuscript. Each statement was voted through a web survey to reach a consensus. RESULTS Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort studies) have been published regarding the applications of robotics for emergency general surgery procedures. Due to the paucity and overall low quality of evidence, 6 statements are proposed as expert opinions. In general, the experts claim for a strict patient selection while approaching emergent general surgery procedures with robotics, eventually considering it for hemodynamically stable patients only. An emergency setting should not be seen as an absolute contraindication for robotic surgery if an adequate training of the operating surgical team is available. In such conditions, robotic surgery can be considered safe, feasible, and associated with surgical outcomes related to an MIS approach. However, there are some concerns regarding the adoption of robotic surgery for emergency surgeries associated with the following: (i) the availability and accessibility of the robotic platform for emergency units and during night shifts, (ii) expected longer operative times, and (iii) increased costs. Further research is necessary to investigate the role of robotic surgery in emergency settings and to explore the possibility of performing telementoring and telesurgery, which are particularly valuable in emergency situations. CONCLUSIONS Many hospitals are currently equipped with a robotic surgical platform which needs to be implemented efficiently. The role of robotic surgery for emergency procedures remains under investigation. However, its use is expanding with a careful assessment of costs and timeliness of operations. The proposed statements should be seen as a preliminary guide for the surgical community stressing the need for reevaluation and update processes as evidence expands in the relevant literature.
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Affiliation(s)
- Nicola de’Angelis
- Unit of Digestive, Hepatobiliary, and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), Créteil, France
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France
| | - Jim Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, Southwick Hill Road, Cosham, Portsmouth, UK
| | - Francesco Marchegiani
- First Surgical Clinic, Department of Surgical Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy
| | - Giorgio Bianchi
- Unit of Digestive, Hepatobiliary, and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), Créteil, France
| | - Filippo Aisoni
- Unit of Digestive, Hepatobiliary, and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), Créteil, France
| | - Daniele Alberti
- Department of Pediatric Surgery, Spedali Civili Children’s Hospital of Brescia, Brescia, BS Italy
| | - Luca Ansaloni
- General Surgery, San Matteo University Hospital, Pavia, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA USA
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Enrico Cicuttin
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Mathieu D’Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | - Salomone Di Saverio
- Department of Surgery, Cambridge University Hospital, NHS Foundation Trust, Cambridge, UK
| | - Michele Diana
- Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Eloy Espin-Basany
- Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Jeffry Kashuk
- Department of Surgery, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Ewout Kouwenhoven
- Department of Surgery, Hospital Group Twente ZGT, Almelo, Netherlands
| | - Ari Leppaniemi
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nassiba Beghdadi
- Unit of Digestive, Hepatobiliary, and Pancreatic Surgery, CARE Department, Henri Mondor University Hospital (AP-HP), Créteil, France
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, General Regional Hospital “F. Miulli”, Acquaviva delle Fonti, Bari, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, “Federico II” University of Naples, Naples, Italy
| | - Ernest Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO USA
| | | | - Patrick Pessaux
- Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- Institute for Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Institute of Viral and Liver Disease, INSERM U1110, Strasbourg, France
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Michele Pisano
- 1St General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland
| | | | - Giuseppe Spinoglio
- IRCAD Faculty Member Robotic and Colorectal Surgery-IRCAD, Strasbourg, France
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Donegal, Ireland
| | - Edward Tan
- Department of Surgery, Trauma Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Paschalis Gavriilidis
- Department of HBP Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX UK
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, Cesena, Italy
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27
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Kulshrestha S, Janjua HM, Bunn C, Rogers M, DuCoin C, Abdelsattar ZM, Luchette FA, Kuo PC, Baker MS. State-Level Examination of Clinical Outcomes and Costs for Robotic and Laparoscopic Approach to Diaphragmatic Hernia Repair. J Am Coll Surg 2021; 233:9-19.e2. [PMID: 34015455 DOI: 10.1016/j.jamcollsurg.2021.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/30/2021] [Accepted: 05/03/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Sujay Kulshrestha
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL.
| | - Haroon M Janjua
- Department of Surgery, University of South Florida, Tampa, FL; OnetoMap Analytics, University of South Florida, Tampa, FL
| | - Corinne Bunn
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL
| | - Michael Rogers
- Department of Surgery, University of South Florida, Tampa, FL
| | | | - Zaid M Abdelsattar
- Depatment of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr Veterans Administration Hospital, Hines, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr Veterans Administration Hospital, Hines, IL
| | - Paul C Kuo
- Department of Surgery, University of South Florida, Tampa, FL; OnetoMap Analytics, University of South Florida, Tampa, FL
| | - Marshall S Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines, Jr Veterans Administration Hospital, Hines, IL
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28
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Ceccarelli G, Pasculli A, Bugiantella W, De Rosa M, Catena F, Rondelli F, Costa G, Rocca A, Longaroni M, Testini M. Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review. World J Emerg Surg 2020; 15:37. [PMID: 32487136 PMCID: PMC7268602 DOI: 10.1186/s13017-020-00316-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 05/14/2020] [Indexed: 12/15/2022] Open
Abstract
Background Giant hiatal hernia (GHH) is a condition where one-third of the stomach migrates into the thorax. Nowadays, laparoscopic treatment gives excellent postoperative outcomes. Strangulated GHH is rare, and its emergent repair is associated with significant morbidity and mortality rates. We report a series of five cases of strangulated GHH treated by a minimally invasive laparoscopic and robot-assisted approach, together with a systematic review of the literature. Methods During 10 years (December 2009–December 2019), 31 patients affected by GHH were treated by robot-assisted or conventional laparoscopic surgical approach. Among them, five cases were treated in an emergency setting. We performed a PubMed MEDLINE search about the minimally invasive emergent treatment of GHH, selecting 18 articles for review. Results The five cases were male patients with a mean age of 70 ± 18 years. All patients referred to the emergency service complaining of severe abdominal and thoracic pain, nausea and vomiting. CT scan and endoscopy were the main diagnostic tools. All patients showed stable hemodynamic conditions so that they could undergo a minimally invasive attempt. The surgical approach was robotic-assisted in three patients (60%) and laparoscopic in two (40%). Patients reported no complications or recurrences. Conclusion Reviewing current literature, no general recommendations are available about the emergent treatment of strangulated hiatal hernia. Acute mechanical outlet obstruction, ischemia of gastric wall or perforation and severe bleeding are the reasons for an emergent surgical indication. In stable conditions, a minimally invasive approach is often feasible. Moreover, the robot-assisted approach, allowing a stable 3D view and using articulated instruments, represents a reasonable option in challenging situations.
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Affiliation(s)
- Graziano Ceccarelli
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Alessandro Pasculli
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy.
| | - Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Michele De Rosa
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Parma University Hospital, Viale Antonio Gramsci 11, 43126, Parma, Italy
| | - Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Gianluca Costa
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Via Francesco de Sanctis 1, 86100, Campobasso, Italy
| | - Mattia Longaroni
- General Surgery, "San Giovanni Battista" Hospital, USL Umbria 2, Via Massimo Arcamone 1, 06034, Foligno, Italy
| | - Mario Testini
- Unit of General Surgery "V. Bonomo", Department of Biomedical Sciences and Human Oncology, University of Bari "A. Moro", Polyclinic of Bari, Piazza Giulio Cesare 11, 70124, Bari, Italy
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