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BACKGROUND: Giant hiatal hernias with intrathoracic stomach have not been amenable to repair using laparoscopy. Conventionally, the surgical approach to these large hernias has been through a thoracotomy or laparotomy or the use of a hiatal patch with laparoscopy. Historically, independent of the approach, the results of surgical repair have been disappointing. By virtue of three-dimensional visualization and greater instrument maneuverability, the robot can allow for a laparoscopic approach for the dissection of the intrathoracic stomach and primary repair of the giant hiatal hernia.
METHODS: In a 10 month period, 5 patients with an intrathoracic upside down stomach and a giant hiatal hernia underwent a robotic laparoscopic approach. The robot was introduced through 4 trocars. The intra thoracic dissection of the hernia sac and the stomach was performed robotically. The right and left crus were dissected, hiatal closure was performed primarily using 0 Ethibond suture with pledgets of vicryl mesh. A concomitant anti-reflux procedure was performed in all patients. The success of the procedure was assessed by intra-operative endoscopy and post-operative esophagram. Subjective symptoms were assessed by a symptom interview. Objective symptoms were assessed by third party Viscik grading.
RESULTS: There were 2 men, 3 women, mean age 56 years. The procedure was assessed to be successful in all patients based on endoscopy and esophagram. All patients were asymptomatic and were graded as Viscik I at 1 day, 2 weeks, and 10 months. There was no recurrence of hiatal hernia.
CONCLUSION: Robotics enables a complete dissection of the hernia sac and reduction of the intrathoracic stomach in patients with giant hiatal hernias. Although greater experience is necessary, robotics may represent a more viable minimally invasive approach with primary closure of the hiatus in patients with giant hiatal hernias.