Robotic-assisted hiatal hernia surgery with the da Vinci system: A 2-year experience in a single institution

Original Article

Robotic-assisted hiatal hernia surgery with the daVinci system: A 2-year experience in a singleinstitution

Arun Prasad a,*, Ramesh Kumar Aggarwal b, Abhishek Tiwari c,Vachan S. Hukkeri d

aSr. Consultant, General Surgery, Indraprastha Apollo Hospital, New Delhi, IndiabDNB Resident, General Surgery, Indraprastha Apollo Hospital, New Delhi, IndiacSr. Registrar, General Surgery, Indraprastha Apollo Hospital, New Delhi, IndiadDNB Resident, GI Surgery, Indraprastha Apollo Hospital, New Delhi, India

1. Introduction/Background

Robotic-assisted surgery for benign esophageal disease isdescribed for the treatment of achalasia, epiphrenic diverticu-la, refractory reflux, paraesophageal hernias, duplicationcysts, and benign esophageal masses, such as leiomyomas.1

While conventional laparoscopic repair for giant hiatal herniasis considered difficult, robotic technology is likely to result inan improved postoperative course.2

Morelli et al.3 in their prospective study of 3 years withrobotic da Vinci system included 6 patients for giant hiatalhernia repair, they showed that robotic approach in hiatal

hernia repair can minimize the surgical trauma and lead toless anatomical recurrence and better quality of life.

Seetharamaiah R et al.4 in their study concluded that ingiant paraoesophageal hernia repair using robotic systemresults in less recurrence but no significant difference in termof post operative morbidity and operative time.

DraaismaWA et al. 5 in their prospective cohort study on 40consecutive patients showed that robot-assisted laparoscopicHH repair proved to be an effective technique with a relativelylow mid-term recurrence rate.

In this study, we measured the post operative outcomes interm of morbidity, pain and recurrence rate following robotichiatal hernia repair.

a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 1 1 2 – 1 1 4

a r t i c l e i n f o

Article history:

Received 9 May 2015

Accepted 14 May 2015

Available online 15 June 2015

Keywords:

HH (hiatal hernia)

Robotic da Vinci system

Fundoplication recurrence

Scarring

a b s t r a c t

Studies reporting on the recurrence rate after laparoscopic repair of large hiatal hernias (HH),

including anatomical asymptomatic recurrence, are scarce.

So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease

(GERD) is still obscure. In this prospective study, we analyzed the da Vinci Intuitive Surgical

robotic system for antireflux surgery. In August 2012, we set up a pilot study to evaluate the

efficacy of laparoscopic telerobotic surgery using the three-arm da Vinci system. Optimal

trocar positions, operating and setup times, conversion rate, intraoperative complications,

and perioperative morbidity, as well as mortality rate, were analyzed.

# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights

reserved.

* Corresponding author. Tel.: +91 11 29871368; fax: +91 9811082425.E-mail address: surgerytimes@gmail.com (A. Prasad).

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/apme

http://dx.doi.org/10.1016/j.apme.2015.05.0150976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

2. Aim

It is a kind of pilot, feasibility study aimed to evaluate theoutcome of robotic hiatal hernia surgery in terms ofpostoperative morbidity, (pain, vomiting, and conversion),hospital stay, and recurrence.

3. Methods

Setting: 750 bedded hospital, �2-year study duration

Design: Prospective pilot observational feasibility studyTenure: August 2012 to August 2014Study population: 20 patients undergoing surgery for hiatalhernia repair robotically (12 females, 8 males) followed forat least 6 months for the assessment of postoperative pain,vomiting, postoperative hospital stay, scarring, recurrenceof herniaSurgery: standard surgical techniques

All the patients underwent for fundoplication procedurePort placement for robotic hiatal hernia repair.

4. Results

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Twenty patients with giant hiatal hernias underwent roboticrepair using the da Vinci surgical system. The mean operativetime was 90 min. The mean hospital stay was 4 days. Nopatients required reoperation for disease recurrence, andnearly all claimed the absence of postoperative symptoms.

This offers several potential benefits, including significantlyless pain, less blood loss, less risk of infection, less scarring, andshorter hospital stay. The operating team experienced thesupport of the robotic system as beneficial, especially in thedissection of the hernia sac and extensive crural repair, quickerrecovery time, and better clinical outcomes in many cases.

5. Conclusion

Robotic approaches can minimize surgical trauma in patientswith giant hiatal hernias, and result in favourable outcomes interms of anatomical recurrence and quality of life. With theavailability of the da Vinci system, all the patients with gianthiatal hernias can be offered a minimally invasive surgicaloption. However, larger series with longer follow-up arenecessary to further substantiate our results.

Conflicts of interest

The authors have none to declare.

Acknowledgements

We are thankful to our nursing staff for their selfless patientcare and to our fellow doctors who helped us perform thisstudy.

r e f e r e n c e s

1. Hanna JM, Onaitis MW. Robotic benign esophagealprocedures. Thorac Surg Clin. 2014;24(May (2)):223–229. http://dx.doi.org/10.1016/j.thorsurg.2014.02.004. vii.

2. Gehrig T, Mehrabi A, Fischer L, et al. Robotic-assistedparaesophageal hernia repair – a case-control study.Langenbecks Arch Surg. 2013;398(June (5)):691–696. http://dx.doi.org/10.1007/s00423-012-0982-0 [Epub 2012 Jul 31].

3. Morelli L, Guadagni S, Mariniello MD, et al. Robotic gianthiatal hernia repair: 3 year prospective evaluation and reviewof the literature. Int J Med Robot. 2015;11(March (1)):1–7. http://dx.doi.org/10.1002/rcs.1595 [Epub 2014 May 28].

4. Seetharamaiah R, Romero RJ, Kosanovic R, et al. Roboticrepair of giant paraesophageal hernias. JSLS. 2013;17(October–December (4)):570–577.

5. Draaisma WA, Gooszen HG, Consten EC, Broeders IA. Mid-term results of robot-assisted laparoscopic repair of largehiatal hernia: a symptomatic and radiological prospectivecohort study. Surg Technol Int. 2008;17:165–170.

Scarring is very minimal, as port size maximum incision is12 mm in comparison to 7–8 in. in open surgery.

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