Robotic Laparoscopic Repair Of Giant Paraesophageal Hernias With Primary Repair
Farid Gharagozloo, Barbara Tempesta.
Florida Hospital Celebration Health/ University of Central Florida, Celebration, FL, USA.
OBJECTIVE: Giant PHH (GPHH) are characterized by migration of more than 1/3 of the stomach through the esophageal hiatus into the thorax. Surgical correction of PHH is indicated in all symptomatic patients. Laparoscopic Repair requires the use of mesh and is associated with high recurrence rate. The surgical robotic system may address the limitation of traditional laparoscopy by allowing precise and accurate dissection of the esophageal hiatus, hernia sac, and the intrathoracic structures.
METHODS: The study was a retrospective evaluation of prospectively accrued data for all patients who underwent elective robot-assisted laparoscopic repair of GPHH with primary repair of the esophageal hiatus from October 2012 to December 2016. Diagnosis of GPHH was made by Endoscopy, UGI contrast radiography and Computer tomography. Patients were assessed by Preoperative and postoperative ( at 2 weeks, 1 month and annual) Subjective Symptom Questionnaire (Pain, Dysphagia, Heartburn and Regurgitation), and Objective Visick Score. Recurrence was assessed by Upper GI Endoscopy and Contrast radiography at 3 months and annual intervals.
RESULTS: 312 patients underwent robotic assisted laparoscopic repair of GPHH. There were 117 men, 195 women, with average age 65 +/- 8 years. Mean Operative time was 87 +/- 16 minutes. Conversion rate was 0.6%1 patient underwent conversion to laparotomy. 8 patients had postoperative ileus. There were no intra-operative complications. Median length of stay was 4 days (range 2-10 days). Mean follow up was 28 months. Subjective Symptom Questionnaire score decreased from 9.4 +/-1. 3 to 1.4 +/-1 . At the time of surgery all patients were Visick 3 and 4. The Visick score was 1 in 309 patients ( 99%) of patients at the time of last follow up. Recurrence rate was 3/312 (1%). One patient had an iatrogenic diaphragmatic hernia and two had recurrence at the hiatus.
CONCLUSIONS: Robotic laparoscopic repair of giant hiatal hernias with primary hiatal repair is feasible and is associated with better symptom relief and lower recurrence rate compared to laparoscopy. These results may be due the advantages of the surgical robot in facilitating a better hiatal and intrathoracic mediastinal dissection.
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