Robotic hiatal hernia repair and antireflux surgery

Introduction

Gastroesophageal reflux disease (GERD) is one of the most common chronic diseases, affecting 18%–28% of the population in North America, and its prevalence has been increasing steadily with time. Nissen fundoplication is a safe and effective therapy for controlling patients’ reflux symptoms and has emerged as the gold standard surgical treatment for GERD. Robotic surgery has emerged as a useful alternative as it allows for stereoscopic vision, articulating instruments, and tremor reduction, thereby enabling a more elegant dissection. This chapter describes perioperative care, operative techniques, management and complications, and outcomes for the robotic Nissen fundoplication and LINX (Torax Medical Inc., Shoreview, MN, USA) placement procedures.

Indications/workup

Routine upper endoscopy is performed for patients suffering from GERD or other symptoms suggestive of hiatal hernia. The study will clarify the presence or absence of a hiatal hernia and whether there is esophagitis or Barrett’s esophagus. A pH study is still the gold standard for diagnosing GERD associated with hiatal hernia. This can be undertaken in an ambulatory fashion with a pH sensor attached to the distal esophagus. If Los Angeles classification C or D esophagitis is detected on endoscopy, the diagnosis is confirmed without pH testing.

A videoesophagram is performed to evaluate the esophageal anatomy and motility. High-resolution manometry is used as a confirmative study for any dysmotility seen on fluoroscopy.

Once motility disorders and other abnormalities are ruled out as a cause of the patient’s symptoms and there is a definitive diagnosis, the patient is counseled on treatment options. There is consensus that asymptomatic type I hiatal hernias do not require operative intervention. A long-term retrospective review demonstrated that out of 192 respondents, no patients required emergency repair of their type I hiatal hernia after at least 10 years of follow-up.

Description of the procedures