Robot foregut surgery

Introduction

Foregut surgery is a broad term that encompasses a range of disease pathology and procedures. In this chapter, we will discuss the basic construct and robotic technique for four different foregut procedures—paraesophageal hernia repair, Nissen fundoplication, Toupet fundoplication, and Heller myotomy. The field of foregut surgery is a dynamic one, with continual changes in operative technique leading to improved patient outcomes. Surgeries that were once performed open have been successfully performed laparoscopically; those that were once performed laparoscopically are now being performed with robotic assistance.

Hiatal hernias are divided into four types based on their anatomic classification. A type I hernia is also known as a sliding hiatal hernia; the stomach and fundus remain below, and the gastroesophageal junction (GEJ) migrates above the diaphragm. A type II hernia is a pure paraesophageal hernia; in this type, the GEJ retains its normal anatomic position, but a portion of the fundus hernia goes through the diaphragmatic hiatus adjacent to the esophagus. A type III hernia is a combination of types I and II: the GEJ and fundus herniate through the hiatus with the fundus just above the GEJ. A type IV hernia is one in which an abdominal structure other than the stomach, such as the colon, small bowel, or omentum, herniate through the diaphragmatic hiatus within the hernia sac. A paraesophageal hernia includes types II–IV.

Paraesophageal hernias (PEH) were documented as far back as the sixteenth century. Minimally invasive surgery has been demonstrated to be a safe approach for giant PEH with decreased rates of morbidity and mortality as compared to open surgeries and has experienced exponential growth since its introduction. While the introduction of laparoscopic PEH repair has led to improvements, it still falls short—high mediastinal dissection and low-tension hiatal reconstruction can be significant challenges while operating laparoscopically, and recurrence rates can be as high as 57% even in high volume centers. Robotic-assisted surgery has addressed these shortfalls by providing surgeons with increased degrees of freedom, longer instrumentation, enhanced surgeon-controlled visualization, and improved ergonomics. Additionally, literature has demonstrated that many surgeons rely on robotic-assisted surgery for recurrent hiatal hernias. ^, The advantages of robotic-assisted PEH repair include decreased postoperative pain, decreased recurrence rates, the ability to repair larger defects that traditionally required open surgery, and decreased length of stay.

Many patients with PEH also report symptoms of gastroesophageal reflux disease (GERD). The role of hiatal hernias in GERD has been debated over the years, with many studies demonstrating that hiatal hernias are closely related to reflux symptoms, reflux esophagitis, Barrett esophagitis, and esophageal adenocarcinoma. There are four primary and widely accepted fundoplication operations for the treatment of GERD—Nissen fundoplication, Toupet fundoplication, Belsey fundoplication, and Dor fundoplication.

Achalasia is a debilitating esophageal condition, impacting 6 in 100,000 individuals, and is the second most common functional disorder of the esophagus requiring operative treatment. Achalasia is a motility disorder characterized by the failure of the lower esophageal sphincter relaxation and an absence of esophageal peristalsis. A variety of treatment modalities exist, including medical management, with treatments such as calcium channel blockers, nitroglycerine, botulinum toxin injections, and pneumatic balloon dilations, and surgical, including laparoscopic, robotic, and peroral endoscopic approaches.

This chapter discusses the basic principles and operative techniques of paraesophageal hernia repair, GERD treatment with either Nissen or Toupet fundoplication, and Heller myotomy. Specialty equipment required for these procedures is listed in the box that follows.

Patient selection and preparation

For those patients with concern for an isolated paraesophageal hernia, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for workup of an asymptomatic hiatal hernia can include the following studies: plain chest radiographs, contrast studies, computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), esophageal manometry, pH testing, nuclear medicine studies, transesophageal echocardiogram, and endoscopic ultrasound. These tests can be used to confirm or rule out the presence of a paraesophageal hernia. Plain chest radiographs may identify either air fluid levels within the chest or the presence of a soft tissue opacity. Contrast studies can help determine the size and reducibility of the hiatal hernia, while also allowing for localization of the GEJ, and potentially raising concerns for the possible existence of a short esophagus. CT scans allow for clear visualization of any organs potentially herniated into the thoracic cavity while also allowing for 3D reconstruction to aid in preoperative assessment and planning. EGD allows for direct visualization of the esophageal, stomach, and duodenal mucosa to help identify the presence of erosive esophagitis or Barrett esophagus; it can also aid in the diagnosis of the size and type of hernia present. Esophageal manometry and pH testing play more of a role in the workup of GERD and provide valuable information on motility of the esophagus and acid exposure which may alter surgical planning. Nuclear medicine studies, transesophageal echocardiogram, and endoscopic ultrasound are not typically used for the diagnosis of hiatal hernias but may demonstrate these as an incidental finding while the patient is being evaluated for other health conditions.

For those patients who have either failed medical management of their GERD or desire operative intervention for it, a preoperative evaluation and work up must be completed. Preoperative testing must be completed in any patient prior to operative intervention and include upper endoscopy, pH testing, barium swallow evaluation, and manometry; gastric emptying studies should also be obtained in select individuals. Upper endoscopy should be performed preoperatively in all patients to assess for evidence of Barrett esophagus, stricture, and/or esophagitis.

SAGES has published guidelines on indications for surgical intervention on each type of hiatal hernia. For a type I hernia in a patient without GERD, surgery is not necessary. The only indication for surgical repair of a type I hernia would be GERD, and a fundoplication to address the reflux disease is mandatory. SAGES provides a strong recommendation that all symptomatic PEH should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus. SAGES also rated the evidence to support repair of a completely asymptomatic PEH as weak, stating that consideration for surgery should include the patient’s age and comorbidities.

For patients suspected of having achalasia, a thorough preoperative evaluation is imperative. Typical symptoms include dysphagia with solids and liquids, regurgitation of undigested food, weight loss, chest pain, nocturnal cough, and heartburn. A barium esophagram can be used to confirm the diagnosis and demonstrates a smooth tapering of the lower esophagus leading to the closed lower esophageal sphincter, with the image resembling a “bird’s beak.” Additional testing to confirm diagnosis and judge severity includes esophageal manometry and upper endoscopy. Manometry for a patient with achalasia will demonstrate esophageal aperistalsis and insufficient lower esophageal sphincter relaxation with swallowing. Upper endoscopy is imperative to rule out an alternative diagnosis, such as pseudoachalasia due to a tumor at the GEJ.

Paraesophageal hernia repair

Like many other surgical procedures, PEH repair has undergone multiple evolutions since its inception. In 2000, Hashemi et al. published their early results comparing laparoscopic to open PEH repair and found that, at that time, laparoscopic repair was associated with a 42% recurrence rate. As use of laparoscopy became more widely adopted and further studies were completed, the recurrence rate became equivalent to open repair, and laparoscopic repair was associated with a shorter overall hospital stay and fewer postoperative complications. As the use of robotic-assisted surgery has become more prevalent, its use in PEH repair has become more universally adopted. Multiple studies have demonstrated that use of robotic-assisted surgery for hiatal hernia repair is associated with significantly shorter length of stay and lower rates of complications, while having similar operating times without differences in readmission rate and mortality as compared to laparoscopic repair. ^{, ,} Recurrent hiatal hernia repair is known to be associated with higher morbidity and mortality as compared to primary repair, as well as being more technically demanding. Use of robotic-assisted surgery for these operations as compared to laparoscopy has been demonstrated to be associated with lower rates of conversion to open procedures and reduced length of hospital stay.