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Robotic Laparoscopic Transhiatal Anatomic Repair of Hiatal Hernias

Thursday, September 8, 2022

Gharagozloo F. Robotic Laparoscopic Transhiatal Anatomic Repair of Hiatal Hernias. September 2022. doi:10.25373/ctsnet.21042667

Although laparoscopic Nissen fundoplication is the most common procedure for hiatal hernia (HH) repair, HH recurrence because of the breakdown of the hiatoplasty and intrathoracic migration of the wrap has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation, but has greater morbidity (1–5). Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH (6–8).



The accompanying video details a retrospective review performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated gastroesophageal reflux disease-health-related quality of life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick scale Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram, or endoscopy. The preoperative data was then compared to the results at two years.

The results showed that of the 396 patients who underwent RAPR, the median GERD-HRQL score was 42 (range 38–45) preoperatively and 6 (range 0–14) at two years (p < 0.05). Preoperatively, 87 percent of patients were graded as Visick IV. At two years, 95 percent were graded as Visick I. HH recurrence occurred in four out of the 396 patients, or just 1 percent.

The conclusion was made that RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding which operation to perform in patients with large paraesophageal hiatal hernias.


  1. Luketich, J.D., Nason, K.S., Christie, N.A., Pennathur, A., Jobe, B.A., Landreneau, R.J., et al . (2010) Outcomes after a Decade of Laparoscopic Giant Paraesophageal Hernia Repair. The Journal of Thoracic and Cardiovascular Surgery, 139, 395-404.
  2. Rathore, M.A. andrabi, S.I.H., Bhatti, M.I., Najfi, S.M.H. and McMurray, A. (2011) Metaanalysis of Recurrence after Laparoscopic Repair of Paraesophageal Hernia. JSLS, 11, 456-460.
  3. Laan, D.V., Agzarian, J., Harmsen, W.S., Shen, K.R., Blackmon, S.H., Nichols, F.C., Cassivi, S.D., Wigle, D.A. and Allen, M.S. (2018) A Comparison between Belsey Mark IV and Laparoscopic Nissen Fundoplication in Patients with Large Paraesophageal Hernia. The Journal of Thoracic and Cardiovascular Surgery, 156, 418-428.
  4. Carrott, P.W., Hong, J., Kuppusamy, M., Koehler, R.P. and Low, D.E. (2012) Clinical Ramifications of Giant Paraesophageal Hernias Are Underappreciated Making the Case for Routine Surgical Repair. The Annals of Thoracic Surgery, 94, 421.
  5. Morrow, E.H., Chen, J., Patel, R., Bellows, B., Nirula, R., Glasgow, R. and Nelson, R.E. (2018) Watchful Waiting versus Elective Repair for Asymptomatic and Minimally Symptomatic Paraesophageal Hernias: A Cost-Effectiveness Analysis. The American Journal of Surgery, 216, 760-763.
  6. Gharagozloo, F., Meyer, M. and Poston, R. (2022) Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review. World Journal of Cardiovascular Surgery, 12, 39-69.
  7. Gharagozloo, F., Meyer, M. (2022) Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias. World Journal of Cardiovascular Surgery, 12, 85-104.
  8. Gharagozloo F. Robotic Repair of Giant Hiatal Hernias. Chapter in Gharagozloo F, Patel V, Giulianotti P, Poston R, Gruessner R, Meyers M: (eds.) Robotic Surgery. Second Edition, Springer, 2021.


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Sorry but cannot see what the robot is adding to that mediastinal mobilisation? Many many people have done this type of mobilisation for 20 years and more by laparoscopy. Just need to lower the insufflation pressure to avoid any physiologic problem. Furthermore some few people will still need a Collis despite such a mobilisation. But probably your secret powder makes all the difference!
Thank you Dr. Decker. I must agree with your excellent comments. The mediastinal dissection can be performed either by robotics or laparoscopic technique. Robotic dissection may be more important for a less experienced surgeon who will have a more controlled environment and may not be familiar with the techniques that are used by more experienced surgeons such as you. However, the most important message is that an anatomic reconstruction of the hiatus with a Belsey Type fundoplasty may be more advantageous than Nissen fundoplication. Thank you again.

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