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Early Experience with Robotic-Assisted Laparoscopic Giant Paraesophageal Hernia Repair
Inderpal S. Sarkaria, Nabil P. Rizk, David J. Finley, James Huang, Prasad Adusumilli, Manjit S. Bains.
Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
BACKGROUND: Laparoscopic giant paraesophageal hernia repair (GPEHR) is gaining wider acceptance, with reported outcomes comparable to traditional operative approaches. We report our early experience with a robotic assisted laparoscopic approach to the repair of these hernias. Our objective was to assess the feasibility of this approach.
METHODS: Initial cadaveric evaluation was performed to assess optimal port placement and feasibility of high mediastinal dissection of the esophagus using a four arm robotic platform. Consecutive patients presenting with GPEH then underwent robotic assisted giant paraesophageal hernia repair (RA-GPEHR). Peri-operative outcomes were assessed.
RESULTS: Two initial cadaveric laboratory sessions helped establish optimal port-placement and methodology for RA-GPEH. From 4/11/2011-11/7/2011, 6 patients with symptomatic GPEH underwent RA-GPEHR. Median age was 72, median procedure time 395 minutes, and median blood loss 150 mL (Table). Major peri-operative complications included 1 myocardial ischemia and 1 pulmonary embolism. No patients had post-operative dysphagia and mortality was zero. All patients returned to pre-operative functional status.
Patient | Age (years) | Nissen vs. Pexy | TIME (minutes) | EBL (mL) | LOS (days) |
1 | 82 | PEXY | 418 | 100 | 10 |
2 | 59 | NISSEN | 320 | 200 | 4 |
3 | 82 | PEXY | 233 | 20 | 3 |
4 | 73 | NISSEN | 485 | 300 | 6 |
5 | 44 | NISSEN | 385 | 200 | 14 |
6 | 71 | PEXY | 402 | 50 | 4 |
CONCLUSIONS: RA-GPEH is feasible and appears safe in this early experience with limited patients. Peri-operative short-term outcomes are preliminarily comparable to reported laparoscopic approaches, although operative times early in the learning curve are long. The greatest putative advantage seems to be during sac excision and high-mediastinal dissection, in which articulating “wristed” instruments, magnified optics, and camera steadiness were felt to provide an advantage over standard laparoscopic techniques in the confines of this limited anatomic space. Robotic assistance seemed also to enhance crural repair, esophageal fat pad dissection, and gastropexy.
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