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Outcomes Of Concomitant Robotic-assisted Hiatal Hernia Repair With Transoral Incisionless Fundoplication (ctif)
Shayan Hosseinzadeh1, Mahsa Shariat1, Angelo Ciaraglia2, Nestor Villamizar2.
1University of Miami, Fort Lauderdale, FL, USA, 2UMiami/ Jackson Health, Miami, FL, USA.
Background: Gastroesophageal reflux disease (GERD) is frequently exacerbated by hiatal hernias, and traditional anti-reflux surgery, while effective, can be associated with postoperative side effects such as dysphagia, gas bloat, and inability to belch. Transoral incisionless fundoplication (TIF) has emerged as a minimally invasive endoscopic alternative, reconstructing the gastroesophageal valve without abdominal incisions. Combining TIF with robotic-assisted hiatal hernia repair (cTIF) offers a single-stage approach to address both anatomic and functional contributors to GERD. However, outcomes data remain limited regarding symptom control, adverse events, and durability of cTIF. This study evaluated early and intermediate outcomes in the first 86 patients undergoing cTIF at a single institution, focusing on GERD-related symptom improvement, adverse events, and postoperative gastrointestinal complaints.
Methods: Patients underwent robotic-assisted hiatal hernia repair using the DaVinci Xi system, immediately followed by TIF under the same anesthetic. Preoperative evaluation included upper endoscopy for all patients, with pH impedance testing and esophageal manometry obtained when feasible. The Gastroesophageal Reflux Symptom Score (GERSS) questionnaire was administered preoperatively and at 2 weeks, 3 months, and 1 year postoperatively to assess heartburn, regurgitation, abdominal distension, dysphagia, cough, and overall satisfaction. Postoperative adverse events, endoscopic findings, and complications were recorded, including the need for dilation or additional interventions. Symptom trajectories were analyzed using linear mixed models.
Results: Eighty-six patients underwent cTIF between February 2021 and October 2023. Median preoperative regurgitation and heartburn scores (both 4) decreased to 1 at 2 weeks, 3 months, and 1 year. Abdominal distension improved from 3 preoperatively to 1 postoperatively, and cough improved significantly at 3 months and 1 year. Dysphagia remained low (median = 1) throughout follow-up. Patient satisfaction improved from a median of -2 preoperatively to 0 at all postoperative time points. Eleven patients (12.8%) required endoscopic dilation, primarily for persistent dysphagia, and three patients (3.5%) experienced significant complications. No patient required conversion to traditional fundoplication or redo surgery. Linear mixed models confirmed sustained symptom improvement at 1 year across regurgitation, heartburn, abdominal distension, cough, and satisfaction.
Conclusions: Concomitant robotic-assisted hiatal hernia repair with transoral incisionless fundoplication is a safe and effective approach for managing GERD in patients with hiatal hernia. In this initial cohort, cTIF achieved significant symptom improvement, low postoperative gastrointestinal morbidity, and avoided reoperation or conversion, supporting its role as a minimally invasive alternative to conventional fundoplication. LEGEND: Longitudinal gastroesophageal reflux symptom outcomes after intervention.
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