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

Operative trends and clinical outcomes of open, laparoscopic and robotic approaches to hiatal and paraoesophageal hernias- a study of 1834 patients

Indications for the repair of hiatal and paraesophageal hernias (HH/PEH) have evolved considerably over the past two decades, largely driven by the growing adoption of minimally invasive surgical (MIS) techniques. This shift highlights the need to assess surgical trends and clinical outcomes associated with open (OPEN), laparoscopic (LAP), and robotic (ROBOT) approaches, particularly in cases involving large hernias, with more than 50% exhibiting intrathoracic gastric content. Understanding these trends is crucial as MIS continues to gain prominence in the management of complex cases, including large hernias. The aim of this study is to evaluate key outcomes during the transition from OPEN and LAP to ROBOT-assisted HH/PEH repair at a high-volume surgical center. This retrospective review examined 1,834 patients who underwent consecutive hiatal and paraesophageal hernia (HH/PEH) repairs-open (OPEN, n = 958), laparoscopic (LAP, n = 390), or robotic (ROBOT, n = 486)-between 2000 and 2023 at a large medical center. All patients were prospectively enrolled in an IRB-approved database. The study assessed trends in surgical technique, hernia size, and length of stay (LOS) over time. Additionally, patient demographics, the three most common preoperative symptoms, hernia type and size, surgical course, and clinical outcomes-including LOS, radiographic recurrence (evaluated by esophagrams at 3 and 12 months), reoperation rates, and postoperative symptom improvement-were also evaluated. Robotic surgery was introduced in 2018, with a steady annual increase in its use. The total number of operations performed also saw a significant rise over the study period. Mean hernia size decreased during the study, and the majority of patients (99.1%) presented with symptoms. Robotic surgery (ROBOT) demonstrated significantly superior symptom resolution compared to open surgery (OPEN) (p < 0.01), with this advantage sustained in patients with large hernias (p < 0.01). Additionally, length of stay (LOS) decreased over time. While the overall radiographic recurrence rate (8.6%) and reoperation rate (2.4%) were comparable across surgical techniques, ROBOT showed a higher radiographic recurrence rate for large hernias (18%, p < 0.01) without increase in reoperations. The volume of surgeries for HH/PEH repair has increased over time, driven by expanding surgical indications and advancements in minimally invasive and robotic techniques. Surgical intervention leads to significant improvements in HH/PEH symptoms, with more pronounced benefits seen in larger hernia cases. Minimally invasive surgery (MIS), particularly robotic surgery, demonstrates notable improvements in length of stay (LOS) and at least equivalent clinical outcomes when compared to traditional approaches. While the rates of anatomic recurrence and reoperation remain relatively low, ongoing evaluation-especially of robotic surgery-is essential to further minimize these occurrences.

Antireflux surgeries and hiatal repair: keys to success

INTRODUCTION

Gastroesophageal reflux is common, and when medical therapy is ineffective, alternative treatments should be considered. Nissen fundoplication controls reflux but can be followed by side effects such as dysphagia and flatulence. To improve outcomes, modifications have been advocated.

AREAS COVERED

Modifications to Nissen fundoplication and newer procedures for gastroesophageal reflux aim to improve overall outcome. Randomized controlled trials (RCTs) and long-term outcomes from large cohorts are prioritized to consider the optimal procedure for reflux and hiatus hernia.

EXPERT OPINION

Fundoplication is an effective treatment for gastroesophageal reflux, with success rates of >80% reported at 18-20-year follow-up. RCTs confirm that Nissen fundoplication delivers better reflux control than medication. However, some patients are troubled by side effects. Anterior and posterior partial fundoplication variants have been proposed as procedures that offer equally good reflux control, but fewer side effects, and RCTs have confirmed this with follow-up to 20 years. Which partial fundoplication is better is debated. Alternative laparoscopic or endoscopic approaches require expensive implants or equipment and deliver less reliable reflux control than partial fundoplication. Currently, level I evidence confirms that laparoscopic partial fundoplication delivers the optimal outcome in fit patients with reflux that is not well controlled by medication.

Optimizing outcomes in paraesophageal hernia repair: a novel critical view

BACKGROUND

The recurrence rate of paraesophageal hernia repair (PEHR) is high with reported rates of recurrence varying between 25 and 42%. We present a novel approach to PEHR that involves the visualization of a critical view to decrease recurrence rate. Our study aims to investigate the outcomes of PEHR following the implementation of a critical view.

METHODS

This is a single-center retrospective study that examines operative outcomes in patients who underwent PEHR with a critical view in comparison to patients who underwent standard repair. The critical view is defined as full dissection of the posterior mediastinum with complete mobilization of the esophagus to the level of the inferior pulmonary vein, visualization of the left crus of the diaphragm as well as the left gastric artery while the distal esophagus is retracted to expose the spleen in the background. Bivariate chi-squared analysis and multivariable logistic and linear regressions were used for statistical analysis.

RESULTS

A total of 297 patients underwent PEHR between 2015 and 2023, including 207 with critical view and 90 with standard repair which represents the historic control. Type III hernias were most common (48%) followed by type I (36%), type IV (13%), and type II (2.0%). Robotic-assisted repair was most common (65%), followed by laparoscopic (22%) and open repair (14%). Fundoplications performed included Dor (59%), Nissen (14%), Belsey (5%), and Toupet (2%). Patients who underwent PEHR with critical view had lower hernia recurrence rates compared to standard (9.7% vs 20%, P < .01) and lower reoperation rates (0.5% vs 10%, P < .001). There were no differences in postoperative complications on unadjusted bivariate analysis; however, adjusted outcomes revealed a lower odds of postoperative complications in patients with critical view (AOR .13, 95% CI .05-.31, P < .001).

CONCLUSION

We present dissection of a novel critical view during repair of all types of paraesophageal hernia that results in reproducible, consistent, and durable postoperative outcomes, including a significant reduction in recurrence and reoperation.

[Surgical strategy for hiatal hernias]

The indications for surgical treatment of hiatus hernias differentiate between type I and types II, III and IV hernias. The indications for a type I hernia should include a proven reflux disease but the indications for surgical treatment of types II, III and IV hernias are mandatory due to the symptoms with problems in the passage of food and due to the sometimes very severe possible complications. The primary aims of surgery are the repositioning of the herniated contents and a hiatoplasty, which includes a surgical narrowing of the esophageal hiatus by suture implantation. In addition, depending on the clinical situation other procedures, such as hernia sac removal, mesh implantation, gastropexy and fundoplication can be considered. There are various approaches to the repair, all of which have individual advantages and disadvantages. An adaptation to the specific needs situation of the patient and the expertise of the surgeon is therefore essential.