The Huge Hiatal Hernias. Can the Robot Help?

Introduction: Over the past decade, laparoscopic surgery became the standard approach for the repair of hiatal hernias. Large hiatal hernias remain challenging to the laparoscopic surgeon. The difficulties originate from the depth of the hernia in the mediastinum as well as the narrow orifice (hiatus) to dissect beyond.
We present a novell study for the robotic repair of 4 large hiatal hernia involving the stomach and other organs in the mediastinum.

Materials and Methods: Four consecutive patients presented to the University of Kansas with huge hiatal hernias. Two patients were males and 2 were females. The mean age was 64.5 ± 12.2. The main symptom was bloating in all patients. Gastroesophageal reflux was a symptom in 2 (50%) patients. Recurrent pneumonia and difficulty of extubation from previous surgery were the main reason for diagnosis in one (25%) patient. The Da Vinci robot was used to perform the entire steps of the procedures in all patients. Dissection was prerformed using either the ultrasonic shears or the electric hook.
The hiatal repair was performed using the Crura Soft Bard mesh® in all patients. Primary repair was not feasible due to the large size of the defect. Intraoperative endoscopy was performed in 2 patients to evaluate the integrity of the esophagus. Three patients had Rosetti-Nissen (360°) fundoplication and one patient had Toupet fundoplication (270°). One patient required Leigh-Collis gastroplasty to overcome a short esophagus.

Results: All patients tolerated the procedures well. Robotic assisted laparoscopic repair was successful in all patients. The mean operative time was 192.5 ± 26.6 minutes. Mean Blood loss was 43.75 ± 41.5 ml. No postoperative mortality. Three patients were extubated immediately postoperatively. One patient developed postoperative pneumonia.
Mean stay in the hospital was 9.5 ± 9.46 days. One patient developed postoperative dysphagia (4 months later) which required esophageal dilation.
Conclusion: These technically challenging hiatal hernias can be repaired successfully with the Da Vinci telesurgical system. It provides the surgeon with the necessary degrees of freedom and the instrument’s length to facilitate a deeper access in the chest through the hiatus.

Session: Poster

Program Number: P523