Robotic Paraesophageal Hernia Repair: The Learning Curve Is Steep

Jeffrey R Watkins, MD, Houssam G Osman, MD, Ernest L Dunn, MD, Rohan Jeyarajah, MD. Methodist Dallas Medical Center

Introduction: We aim to describe the transition from laparoscopy to robotic paraesophageal hernia repair by comparing outcomes of pre- and post-robotic implementation. While the transition from open surgery to laparascopy is well-documented in the literature, very little has been published regarding the transition from laparoscopy to robotic-assisted paraesophageal hernia repair.

Methods and procedures: We reviewed 19 consecutive patients who underwent laparoscopic paraesophageal repair with placement of mesh over a one-year period prior to the introduction of robotic surgery. We then compared these to 11 consecutive patients over a 9-month period who underwent robotic-assisted paraesophageal repairs. All procedures were performed by a single surgeon. Techniques were identical with resection of sac, crural repair, keyhole mesh placement, Dor fundoplication, and gastrostomy tube placement as pexy. Patient charts were reviewed and all relevant data were extracted and evaluated with appropriate statistical analysis performed.

Results: The operative time for robotic surgery was significantly greater than our laparoscopic procedures with an average of 254 minutes versus 186 minutes respectively (p < 0.001). There were four robotic cases that were converted to an open procedure compared with no conversions in our laparoscopic group (p = .01). The length of stay in the robotic procedures was longer – 4.5 days as compared to 3.3 days in the laparoscopic patients (p = 0.10). All hernias were classified as large type III hernias in the laparoscopic group while 8 out of the 9 hernias in the robotic group were classified as such (p = 0.32). Average age, BMI, presence of volvulus, previous hiatal surgery and complications did not differ significantly between the two patient populations.

Conclusions: The transition from laparoscopy to robotics in paraesophageal hernia repair can be a difficult process within the initial period. Caution must be taken as one transitions from laparoscopy to robotics with a clear understanding that there is a steep learning curve for robotic paraesophageal hernia repairs.