Robotic giant paraesophageal hernia repair, the largest single center experience to date

Amit Taggar, MD, Niazy Selim, MD, PhD, Todd Crawford, Will Poulson, Cody Kramer

University of Kansas Medical Center

The repair of paraesophageal hernias (PEH) is a difficult problem with few universally accepted standards. Recently, laparoscopic technique has gained widespread acceptance. However, since the da Vinci robot has become more prominent, we are introducing this modality for the treatment of PEH. The articulation of the Robot arms reduces difficulties that originate with the depth of the hernia in the mediastinum as well as the narrow orifice (hiatus) to dissect beyond. In this study, the authors present the results of the largest data of da Vinci Type IV giant PEH repair to-date.

Methods/Material: 54 patients presented to the University of Kansas Medical Center with giant paraesophageal hernias. 17 (31%) were males and and 37 (69%) were female. The mean age was 62 (SD+/-13).

All procedures were performed using the da Vinci robot. Dissection and excision of the hernia sac was completed using ultrasonic shears or monoploar hook.

The hiatal reinforcement was performed in 36 (67%) patients. Crura Soft Bard mesh® was used in 25/36 (69%) patients, Proceed mesh® in 9/36 (25%), and Flex HD mesh® in 2/36 (3.7%). Posterior bridging mesh was placed in 3/36 patients (8.3%). Primary crural repair and mesh reinforcement posterior to the esophagus was performed in 17 patients (47.2%). A novel anterior mesh placement was used in 12 patients (33.3%). Dual mesh placement (anterior and posterior) was used in 2 patients (3.7%). 2 patients (3.7%) had key hole mesh placement with posterior crural repair. A Nissen Fundoplication was performed in 44 patients (83%). 7 patients had a Toupet fundoplication (13%). 1 (1.9%) patient had a Dor Fundoplication. 2 patients (3.7%) had a gastropexy. 1 patient (1.9%) did not have a fundoplication due to a prior esophagectomy. Leigh-Collis gastroplasty was required in one patient (1.9%).

Patients were monitored for recurrence of paraesophageal hernia using radiographic imaging and esophagoscopy.

Results: All patients were completed using the da Vinci system except 2 patients (3.7%); 1 patient (1.9%) was converted to an open procedure to reduce a friable incarcerated colon and 1 patient (1.9%) was converted to repair colonic and gastric perforations resulting from traumatic grasper. Average blood loss from the procedure was 25ml +/-47. Mean operative time was 150 +/- 55 min. Mean hospital stay was 3.5 +/- 7 days. Mortality occurred in 1 patient (1.9%) as a result of gastric perforation. Esophageal leak occurred in 3 patients (5.5%). One patient (1.9%) was re-operated on via laparoscopy for a total re-operation rate of 1.9%. Eight patients (15%) had temporary postoperative dysphagia while 2 (3.7%) developed strictures and required dilation. Longest follow-up period spanned over 6 years (mean follow-up 50+/-12 months) and no patients developed recurrence of hernias. All patients experienced significant improvement of pre-operative symptoms.

Conclusion: Robotic PEH repair is a suitable method of repairing giant PEH. The outcomes shown in this paper are not only equivalent but superior to the standard laparoscopic approach.

Session: Poster Presentation

Program Number: P305