Hiatal Hernia Repair Research Articles

AHP SO03 - The role of the specialist upper gastrointestinal (UGI) benign dietitian in the management of benign UGI disorders – a review of the outpatient referral base

Abstract Background Benign UGI disorders can negatively affect patients’ nutritional status by impacting on oral intake and/or through malabsorption. GSTT performs a high volume of benign UGI surgeries and is a tertiary referral centre for oesophageal reconstructions and complex hernias. The role of the dedicated specialist UGI benign dietitian was established in 2019 to provide dietetic expertise to the UGI multidisciplinary team (MDT). It supports patients before and after surgery with the aim of reducing post-operative complications, length of hospital stay, re-admissions and improving patient experience and quality of life. Method Outpatient referrals to the UGI benign dietetic service between 02/02/2024 and 06/06/2024 were reviewed for source of referral, reason for dietetic referral and UGI diagnosis. Results Twenty-five new referrals were received from a variety of clinical specialities (table 1). The primary UGI disorders of referrals are outlined in table 2, with complex hernia repair being the most common. Table 3 outlines the broad range referral reasons. Nutrition support referrals were received for the following disorders: achalasia, oesophageal stricture and following oesophageal perforation, hiatus hernia repair, cholecystectomy and oesophagectomy. All weight management referrals were for complex hernia repair patients. Referrals for the side-effects of UGI surgery included dietetic support with pancreatic exocrine insufficiency (pancreatectomy; distal gastrectomy), dumping syndrome (hiatus hernia repair) and delayed gastric emptying (oesophagectomy). Conclusion The role of the benign UGI dietitian requires skills and expertise in a broad range of dietetic interventions. The service is well utilised by surgical and non-surgical colleagues. Next steps for service development would be to review the impact of interventions on surgical and patient reported outcomes, and explore feasibility of patient groups to deliver dietetic advice (for example weight reduction prior to surgery) to improve capacity within the service.

BN SO32 - Operative techniques and outcomes following giant hiatus hernia repair: 5 years of tertiary centre experience

Abstract Background Giant hiatus hernia (GHH) repair is a complex surgical challenge, often requiring advanced techniques and specialised expertise. Whilst the repair of small hiatus hernias is well-documented, the optimal strategy for giant hernias remains debated. This study reviews five years of experience at a tertiary centre, focusing on operative techniques and outcomes. The aim is to identify trends and best practices that enhance patient outcomes and minimise complications in the repair of GHH. Method All patients undergoing primary GHH surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document patient demographics, type of hernia, operative details including surgical approach (open/laparoscopic/robotic), use of fundoplication, use of mesh and gastropexy. Outcomes measured included 30-day morbidity (Clavien-Dindo (CD) grading), 30-day mortality, binary symptom recurrence, length of stay (LOS), need for return to theatre (RTT) and RTT versus mesh use. Analysis undertaken using paired t-test. Statistical significance was set as p<0.05. Results 91 patients underwent GHH repair with median age 70 (31-93) years, 66.7% female, average BMI 30.8(±5.4). ASA: ≤2 (72.4%), 3 (25.5%), 4 (2.1%). Hernia types: 2 (15.7%), 3 (55.4%), 4 (28.9%). Approach: open 6.6%, laparoscopic 61.5%, robotic 31.9%. Fundoplication in 88%, gastropexy in 13%, 2 cases utilised both. Mesh: 91.2% without, 8.8% biologic, nil prosthetic. Median LOS 2 days (0-161). Median follow-up 8 weeks (1-172). Symptoms recurred in 25.6%. 94.5% had no significant complications (CD≤2). 5.5% had RTT≤30 days. 4.4% RTT>30 days. No mortalities. No significant difference in RTT and mesh use (p=0.7832). Conclusion This five-year review confirms that GHH repair using open, laparoscopic, and robotic techniques is effective and safe, even in an older population with high ASA scores. The study highlights minimal complications (94.5% with CD≤2). Only 4.8% required a RTT within 30 days. RTT was not significantly impacted by the use of mesh however this may represent a type two error given the limited use of mesh and low number of patients that RTT. These findings support the tailored use of advanced surgical techniques, mesh, and gastropexy as effective strategies for managing GHH in a tertiary care setting.

BN SO58 - Patient Reported Outcome Measures in Hiatal Surgery: A Feasibility Study

Abstract Background Hiatal surgery is predominantly a quality-of-life procedure rather than a lifesaving intervention. Whilst procedural complications are well understood, they do not necessarily reflect the patient experience. Traditional indicators of patient care are insufficient. Patient Reported Outcome Measures (PROM) are robust indicators of care quality (1) and are being used across surgical specialities to benchmark success and identify areas for improvement (2). We present a three-year review of our PROM data to demonstrate feasibility of data collection. Method Patient reported outcome measure data were collected from the National Hiatal Surgery Registry (3) for our benign centre over a three-year period (November 2021-January 2024). Consent was obtained from all patients for research purposes. Surgical procedures included: anti-reflux surgery, hiatus hernia repair and cardiomyotomy. All patients were asked to complete pre-operative quality of life surveys. Patients are automatically contacted through the registry at 6months, 1 year and then annually for five years and prompted to complete quality of life surveys. Ekhardt score is used in achalasia. GORD-QoL score was used for anti-reflux procedures, with the Hernia-QoL score for hiatal hernia. Results Data were collected for 20 patients. Mean BMI was 28.2. All completed preoperative surveys. At six months there was attrition of one patient, who has since completed 1-year and 2-year data. At the time of writing, six patients have completed 6month data, 5 patients have completed 1-year data and 3 patients have completed 2-year data. Mean Ekhardt score was 9.25 preoperatively; at six months mean score was 0. Five patients underwent LINX, eleven underwent fundoplication; one Dor, ten Toupet. Mean pre-operative quality of life score was 31.1; at six months mean score was 15.5. At one year this was 4. Conclusion The National Hiatal Surgery Registry facilitates easy acquisition of surgeon specific PROM data over a short- and long-term period. Patient attrition is low, demonstrating acceptability. Our data demonstrate significantly improved patient reported quality of life postoperatively for all hiatal surgery.

BN SO53 - Thoracotomy for the Repair of Giant Paraesophageal and Hiatal Hernias: A Systematic Review

Abstract Background The utilisation of transthoracic approaches for the repair of large hiatus hernias remains a topic of clinical debate. This study aims to evaluate and compare the efficacy, safety, and recovery metrics for transthoracic hiatal hernia repair and comparisons to the laparoscopic approach. Method A literature search was conducted using the key terms "hiatus hernia," "thoracotomy," "thoracic approach," and "Belsey Mark IV." The databases searched included MEDLINE, EMBASE, and Web of Science, covering the period from 2000 to June 2024. Extracted data included patient demographics, study design characteristics, length of stay, complication rate and mortality rate. Results A total of 5 citations were selected comprising a total of 560 patients of which 164 were male (29.3%) with an overall mean age was 64.9 (pooled SD = 1.93) and weighted mean follow-up length was 56.4 months (pooled SD = 39.1 months). The weighted overall mean length of stay was 14.5 days (Pooled SD = 7.42). The overall rate of minor complications was 19% (95% CI [6%, 31%]). The overall rate of major complications was 13% (95% CI [6%, 21%]). There were 4 reported mortalities in total and an overall leak rate of 1% (95% CI [0%, 2%]). Conclusion Both thoracotomy and laparoscopy have unique benefits and risks in the context of hiatal hernia surgery. Access via thoracotomy is associated with a higher incidence of complications. However, for large or emergent paraesophageal hernias, the transthoracic approach may represent a viable option in select patients.

BN SO36 - Robotic versus laparoscopic giant hiatus hernia repair - is one superior in clinical outcomes?

Abstract Background The number of robotic giant hiatal hernia repair (RGHHR) procedures is steadily increasing. RGHHR offers several potential advantages over traditional laparoscopy, including enhanced visualisation, superior ergonomics, and the use of articulating instruments, which can be particularly beneficial in the restrictive operating field of the diaphragmatic hiatus. However, the outcomes of RGHHR remain heterogeneous, both when reported alone and in comparison to laparoscopic giant hiatus hernia repair (LGHHR). This study aims to evaluate and compare the key clinical outcomes of RGHHR and LGHHR in adult patients. Method All patients undergoing primary giant hiatus hernia (GHH) surgery between March 2019 and March 2024 at a tertiary institution and a five surgeon upper GI service. Retrospective review of electronic records were utilised to document: patient demographics, hernia type, operative details. Use of mesh and gastropexy (as proxy measures to indicate difficulty of operation). Follow-up duration in weeks. Open cases within this cohort were excluded. Outcomes were: length of stay (LOS), 30-day morbidity measured using Clavien-Dindo (CD) grading, RTT and 30-day mortality. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant. Results Table 1. Patients LGHHR RGHHR p n 56 29 Age (median) 71 (31-93) 66 (39-85) 0.1303 Female (%) 68.7 70 0.8988 BMI 31.8 (±6.4) 29.9 (±3.4) 0.1715 ASA grade (average) 2.4 2.2 0.0587 Hernia Types (median) 3 3 0.4411 Median follow-up (weeks) 8 (1-161) 12 (3-172) 0.5763 Table 2. Operative details LGHHR RGHHR p Mesh used (%) 9.1 0 0.0907 Gastropexy (%) 12.7 6.9 0.4175 Table 3. Outcomes LGHHR RGHHR p LOS (median) 1 (0-161) 2 (0-15) 0.4177 30-day morbidity (CD≥3, %) 3.6 6.9 0.9193 RTT (%) 9.1 6.9 0.5570 30-day mortality 0 0 NA Conclusion RGHHR approach has been successful in managing complex GHH, with low RTT, low co-morbidity and no mortality. In our institution RGHHR has demonstrated non-inferiority to LGHHR in respect to clinical outcomes. Patient factors and hernia types did not affect case selection. Use of mesh and gastropexy showed no difference in outcomes between the two groups. Cost, operative time and surgeon strain/fatigue were not evaluated in this study, however, these would provide useful additional comparative markers for the future.

MS O10 - BN Case Report: Aberrant Right Subclavian Artery As A Rare Differential For Dysphagia

Abstract Background Dysphagia lusoria (DL) is characterised by swallowing difficulty due to external oesophageal compression from congenital aortic arch malformations. It is clinically rare and affects less than 2.5% of the population. The most prevalent form of DL is the aberrant right subclavian artery (ARSA) where approximately 10% of patients experience dysphagia. Despite AL being congenital, dysphagia often manifests later in life, likely due to age-related atherosclerotic changes in the vasculature and decreased oesophageal flexibility. Method Presented is a case report of a female in her seventies where, despite repeat hiatal hernia repair and maximal medical management, her index symptoms of dyspepsia and retrosternal discomfort persisted when reviewed in specialist upper gastrointestinal clinic. She underwent extensive investigation; however, her symptoms were unremitting, manifesting in numerous emergency department presentations to exclude acute coronary syndrome. This case report details the anatomical differences via diagrams and documents the comprehensive investigation and multi-disciplinary approach to the management of dysphagia in ARSA. Results Prior to referral to our team, the patient had a laparoscopic hiatus hernia repair and Nissen fundoplication undertaken. Oesophageal manometry revealed weak oesophageal motility and 24-hour pH monitoring did not demonstrate pathological acid-reflux. Recurrence of hiatus hernia was observed on oral contrast swallow and gastroscopy. Subsequently, the patient underwent laparoscopic revision of hiatus hernia and conversion of Nissen to a Dor. Post-operatively her symptoms required complete fundoplication reversal. Following reversal, assessment demonstrated improved distal oesophageal emptying. Her CT emphasised an ARSA causing significant compression and deviation of the proximal oesophagus. The patient was referred onwards to vascular surgery. Conclusion Initial diagnostic workup for patients presenting with dysphagia in the upper gastrointestinal clinic seeks to encompass several common aetiologies including oesophageal motility disorders, malignant compression and benign strictures. Clinicians must consider less common causes of extrinsic compression, such as ARSA, particularly in patients with unrelenting and persistent symptoms despite appropriate implementation of both medical and surgical interventions. Treatment approaches for ARSA reflect symptom severity, with both conservative and surgical options considered.

BN SO34 - Outcomes in giant versus non-giant hiatus hernia repair: Same payment different operative burden

Abstract Background Hospital trust payment for operative procedures often rely on coding systems like the NHS's Office of Population Censuses and Surveys (OPCS) codes, which determine reimbursement rates. Both giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs often share the same code, as in our trust. This results in equal reimbursement to trusts for procedures with higher operative burden and resource needs. This study aims to assess differences in the patient population, their hiatal type, operative challenges and post-operative outcomes between GHH and NGHH repairs. Method All patients undergoing primary hiatus hernia surgery between March 2019 to March 2024 at a single institution were included. Retrospective review of electronic records were utilised to record: patient demographics, hernia type, operative details, length of stay (LOS), post-operative course and need for a return to theatre (RTT). Outcomes were comparison of surgical approach, use of mesh and gastropexy (as proxy measures to indicate difficulty of operation), 30-day morbidity measured using Clavien-Dindo (CD) grading and 30-day mortality and RTT. Analysis was undertaken using un-paired t-test and Chi2. A p-value of <0.05 was considered statistically significant. Results Table 1. Patients GHH NGHH p n 91 135 Age (average) 69 (±10) 52 (±16) <0.001 Female (%) 66.7 55.2 0.1100 BMI 30.8 (±5.4) 30.7 (±7.8) 0.2029 ASA grade (average) 2.2 1.9 <0.001 Hernia Types (median) 3 1 <0.001 Table 2. Operative details GHH NGHH p Open (%) 6.6 0 0.0020 Laparoscopic (%) 60.4 62.24 0.9840 Robotic (%) 33 33.3 0.9239 Mesh used (%) 8.8 0.7 <0.041 Gastropexy (%) 12 0.7 <0.001 Table 3. Outcomes GHH NGHH p LOS (median) 2 (0-161) 1 (0-8) 0.0179 RTT (%) 10.7 8 0.4747 30-day morbidity (CD≥3, %) 4.8 4.4 0.6519 30-day mortality 0 0 NA Conclusion This study highlights significant differences between giant hiatus hernia (GHH) and non-giant hiatus hernia (NGHH) repairs. GHH repairs have an increased likelihood of undergoing open procedures, use of mesh, and gastropexy, reflecting their greater complexity. GHH patients are older, have higher ASA grades, and present with more advanced hernia types compared to NGHH patients. Additionally, GHH repairs result in longer hospital stays. The findings underscore the need for improved coding accuracy to reflect these disparities accurately in patient demographics, operative strategies, and recovery outcomes within hospital trusts, ensuring appropriate resource allocation and reimbursement based on procedural complexity.

Revision of Laparoscopic Roux-en-Y Gastric Bypass to Laparoscopic Sleeve Gastrectomy with Proximal Jejunal Bypass and Hiatal Hernia Repair.

Revision of Laparoscopic Roux-en-Y Gastric Bypass to Laparoscopic Sleeve Gastrectomy with Proximal Jejunal Bypass and Hiatal Hernia Repair.

Giant Hiatal Hernia and P4HB Phasix TMST Mesh Hiatoplasty Outcomes

Surgical repair of giant hiatal hernia (GHH) and associated high recurrence rate defy technological advances in surgical sciences despite better instrumentation and availability of various mesh prostheses. Aim: This study evaluates the safety and efficacy of long-lasting biosynthetic absorbable Poly 4 Hydroxybutyrate Phasix TMST mesh outcomes in patients with GHH undergoing hiatal hernia repair. Methods: We studied a prospectively maintained database of all patients who underwent GHH repair between September 2020 and October 2023. Primary outcome measures were 30-day mortality and postoperative morbidities. Secondary outcome measures were 90-day readmission rates, patient-reported outcomes derived through modified Visick grading and recurrence of hiatus hernia. Results: 44 patients were included in this study. Median follow-up is twenty-four months. There was no mortality at 30 days. 4.5% (n=2) experienced significant complications at 30 days. Median length of stay was 3 days. 81% reported clinical improvement with enhanced Visick grade, and proton-pump inhibitor (PPI) cessation rate was 77.4%. There were no readmissions at 90 days. 9.1% who reported symptom recurrence had anatomical hiatus hernia recurrence. Conclusion: The study showed laparoscopic hiatoplasty with P4B Phasix TMST mesh has low morbidity and recurrence with medium-term follow-up.

Surgical treatment strategies for gastroesophageal reflux after laparoscopic sleeve gastrectomy.

Bariatric surgery has emerged as an effective therapeutic approach for combating obesity. As the most commonly performed bariatric surgery, laparoscopic sleeve gastrectomy (LSG) has a long-term and effective outcome in weight reduction. However, studies have reported an increased incidence of gastroesophageal reflux disease (GERD) among patients after LSG. For those who fail to respond to conventional oral acid-suppressing medication, surgical intervention comes into consideration. The most commonly performed revisional surgery for sleeve gastrectomy is the Roux-en-Y gastric bypass, which can effectively alleviate the symptoms of reflux in patients and also continues to promote weight loss in patients who have not achieved satisfactory results or have experienced weight regain. In addition to this established procedure, innovative techniques such as laparoscopic magnetic sphincter augmentation (MSA) are being explored. MSA is less invasive, has good reflux treatment outcomes, and its safety and efficacy are supported by the literature, making it a promising tool for the future treatment of gastroesophageal reflux. This article also explores the role of endoscopic interventions for GERD treatment of post-sleeve gastrectomy patients. Although these methods have shown some therapeutic effect, their efficacy still requires further study due to a lack of support from more clinical data. For patients with preoperative hiatal hernia or gastroesophageal reflux symptoms, some experts now consider performing LSG combined with hiatal hernia repair or fundoplication to alleviate or prevent postoperative reflux symptoms. Both of these surgical approaches have demonstrated favorable outcomes; however, the addition of fundoplication requires further investigation regarding its long-term effects and potential postoperative complications. This article gathers and examines the current laparoscopic and endoscopic treatments for refractory gastroesophageal reflux following LSG, as well as the concurrent treatment of LSG in patients with preoperative gastroesophageal reflux or hiatal hernia.

Robot-assisted congenital diaphragmatic hernia repair in adults: A case series.

Congenital diaphragmatic hernia (CDH) is a rare condition predominantly affecting neonates, with only a few cases remaining undetected until adulthood. Surgical repair is the primary treatment approach for adults with confirmed CDH. Traditionally, these procedures include laparotomy, thoracotomy, and minimally invasive techniques such as thoracoscopy and laparoscopy. However, only a few cases of robotic diaphragmatic hernia repair have been reported in recent decades. The patients, aged 31 and 71 years, presented with atypical symptoms of chest tightness and fever. Imaging studies revealed a left-sided Bochdalek CDH in 1 patient and a right-sided Morgagni CDH in the other. The patients were diagnosed as CDH in adult with different symptoms. Both patients received robot-assisted diaphragmatic hernia repair at our institution. The patients received robotic-assisted diaphragmatic hernia repair with acceptable surgery outcome and safety. There was no complication or recurrence. This case series indicates that the robotic transabdominal approach for CDH repair in adults can be an optimal minimally invasive approach for selected patients, demonstrating adequate surgical safety and favorable outcomes.

Comparison of outcomes in dogs undergoing hiatal hernia repair with and without use of a gastropexy: 41 cases (2012-2022).

To determine the difference in complication rate, gastrointestinal grade and requirement for ongoing medical and/or surgical management following hiatal hernia repair in dogs with and without gastropexy. Clinical records were reviewed retrospectively for dogs that had undergone surgical hiatal hernia repair at two veterinary referral centres between April 2012 and March 2022. Pre-operative grading of gastrointestinal signs and brachycephalic obstructive airway syndrome was performed. All dogs had an oesophagopexy and phrenoplasty. Referring primary veterinary practices and clients were contacted to obtain follow-up information. Fisher's exact tests and Mann Whitney tests were used to assess pre- and intra-operative similarities between groups. Wilcoxon signed rank tests were used to determine the changes in gastrointestinal grade at short- (<6 months) and long-term (>6 months) follow-up. Forty-one dogs which underwent oesophagopexy and phrenoplasty were included. Fifteen dogs had no gastropexy performed and 26 dogs had left-sided gastropexy performed. Dogs that underwent gastropexy(n=8, 29%, 95% CI: 13 to 51%) were significantly more likely to require further surgery related to the initial surgery or persistence of gastrointestinal signs compared to dogs that had no gastropexy (n=0, 0%, 95% CI: 0 to 18%) . This difference was not significant when dogs which had further surgery to address brachycephalic obstructive airway syndrome were excluded. Gastrointestinal grade significantly improved for both groups at both short- and long-term follow-up. There was no significant difference in overall complication rate, gastrointestinal grade or requirement for further medical treatment between groups. A left-sided gastropexy is not required for successful surgical repair of hiatal hernia in dogs provided oesophagopexy and phrenoplasty are performed.

Use of Low-Molecular-Weight Heparin for Right Atrial Thrombus Following Extracorporeal Membrane Oxygenation in Neonates after Surgical Repair of Congenital Diaphragmatic Hernia: A Case Report and Review of the Literature

Some critically ill neonates with congenital diaphragmatic hernia (CDH) require extracorporeal membrane oxygenation (ECMO) during the perioperative period. Neonates on ECMO face a significantly increased risk of thrombotic events. Thrombosis management varies across centers and may include anticoagulation, thrombolysis, or thrombectomy. We present our experience using low molecular weight heparin (LMWH) to treat a right atrial thrombus (RAT) following ECMO in a neonate with CDH.

Sliding hiatus hernia (intrathoracic sleeve migration) post-laparoscopic sleeve gastrectomy: A case series and review of literature.

Intrathoracic sleeve migration (ITSM) is a complication that uncommonly occurs post-sleeve gastrectomy, with an incidence rate anecdotally ranging from 5% to 45%. Its treatment has established difficulties by bariatric surgeons worldwide. Sixteen cases were shown in this case series that commonly encountered the symptoms of weight gain, gastro-oesophageal reflux disease (GERD), epigastric pain, globus sensation, nausea and vomiting as their initial complaints before their diagnosis. Moreover, these symptoms began a few years after the gastric sleeve. The confirmatory results through gastrografin and computed tomography abdomen were performed where relevant findings of Grade I or II GERD, sliding hiatal hernia and post-sleeve anatomy were appreciated. In literature, the most common modality used to treat ITSM was the conversion to Roux-en-Y bypass. However, other treatment modalities were also utilised for the cases presented due to the different patients' preferences, including mini-gastric bypass and laparoscopic hiatal hernia repair with/without posterior cruroplasty and buttress plication with the falciform ligament. In addition, anchoring to pre-pancreatic fascia post-gastric sleeve has been shown to prevent such presentations further in the future. Postoperatively, all patients were stable with no complications acutely or after 3 months follow-up. Hence, this concludes that despite Roux-en-Y being considered the golden standard treatment of ITSM, laparoscopic hiatal hernia repair with cruroplasty and plication reflects an equivalent, cost-effective and valuable alternative to treating relevant patients.

Letter to editor in response to 'Systematic Review of the Perioperative Classification, Diagnosis, Description, and Repair of Hiatus Hernias in Randomized Controlled Trials'.

Letter to editor in response to 'Systematic Review of the Perioperative Classification, Diagnosis, Description, and Repair of Hiatus Hernias in Randomized Controlled Trials'.

Impact of pre-existing mesh at the hiatus at revisional hiatal hernia surgery.

Recurrence after laparoscopic hiatus hernia repair (LHR) is high, with few symptomatic patients undergoing redo LHR. Morbidity is higher in redo surgery compared with the primary operation. Tens of studies have explored the safety of redoing LHR. However, the impact of existing mesh on operative risk is rarely examined. We aim to assess the impact of mesh at the hiatus on the safety of redo LHR. This was a cohort study examining redo LHR patients from a prospectively maintained database from January 2002 to December 2023. The primary outcome was intra-/postoperative complications. Follow-up was extracted from clinical records. Predictors of complications were assessed using univariable and multivariable logistic regression analyses. Redo LHR was performed in 100 patients; 22 had previous mesh. One encountered mortality with 23 complications. Five patients had absorbable mesh, with the remainder nonabsorbable. Overall complications were significantly higher with mesh at nine (40.9%) compared to no mesh redo at 14 (17.9%), P = 0.023. There was no difference in rates of visceral injury with mesh at four (18.2%) and no mesh at six (7.7%), P = 0.22. The median follow-up was 7months; there was no difference in reflux rates (P = 0.70) but higher rates of dysphagia (P = 0.010). Higher overall complications were noted in patients with previous hiatal mesh repair at the time of LHR. However, major visceral complications were similar regardless of mesh use. Mesh at the hiatus should not be a deterrent for reoperative hiatus surgery.

Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes.

The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques. We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis. Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196min for robotic compared to 145min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88min for robotic versus 102min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20ml for robotic versus 50ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%). Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.

Challenges With Robot-Assisted Surgery Setup for Complex Minimally Invasive Upper Gastrointestinal Surgery.

The utilization of robot-assisted approaches to surgery has increased significantly over the last two decades. This has introduced novel complexities into the operating room environment, requiring management of new challenges and workflow adaptation. This study aimed to analyze challenges in the surgical setup for complex upper gastrointestinal robot-assisted surgery (UGI-RAS) and identify opportunities for solutions. Direct observations of surgical setup processes for UGI-RAS were performed by a trained Human Factors researcher at a non-profit academic medical center in Southern California. Setup tasks were subdivided into five phases: (1) before wheels-in; (2) patient transfer and anesthesia induction; (3) patient preparation; (4) surgery preparation; and (5) robot docking. Start/end times for each phase/task were documented along with workflow disruption (FD) narratives and timestamps. Setup tasks and FDs were analyzed using descriptive statistics. Twenty UGI-RAS setup procedures were observed between May-November 2023: sleeve gastrectomy +/- hiatal hernia repair (n = 9, 45.00%); para-esophageal hernia repair +/- fundoplication (n = 8, 40.00%); revision to Roux-en-Y gastric bypass (n = 2, 10.00%); and gastric band removal (n = 1, 5.00%). Frequent FDs included planning breakdowns (n = 20, 29.85%), equipment/supply management (n = 17, 25.37%), patient care coordination (n = 8, 11.94%), and equipment challenges (n = 8, 11.94%). Eleven of 20 observations were first-start cases, of which 10 experienced delayed starts. Interventions aimed at improving workflows during UGI-RAS setup include performing pre-operative team huddles and conducting trainings aimed at team coordination and equipment challenges. These solutions could result in improved teamwork, efficiency, and communication while reducing case start delays and turnover time.

Subjective Improvement of Reflux Symptoms After Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass and Concomitant Repair of Hiatal Hernia

BackgroundSymptoms of reflux after SG are common and may be refractory to medical treatment. ObjectivesTo assess outcomes of conversion of SG to RYGB with concomitant repair of hiatal hernias on symptoms of reflux. SettingTertiary Community Hospital MethodsWe reviewed data from all consecutive patients (2018-21) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and post-op PPI use were compared with McNemar statistical test. Data are mean± standard deviation. Results64 patients (92% female; 48±10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4±3 years after the index SG. A hiatal hernia was detected preoperatively in 57/64 patients (89%) by either UGI, CT scan or EGD.At 29±14 months post-conversion to RYGB, TBWL was 14±9%, EWL was 37±29%, BMI decreased from 37±7 to 32±6 Kg/m2. Symptoms of reflux and use of PPI improved during the early follow up period (median: 14 months; p<0.001) and was sustained at late follow up (median: 32 months; p<0.01). Improvement of nausea and dysphagia reached statistical significance at late follow up (median: 32 months; p<0.01). Vomiting and abdominal pain decreased with time but did not reach statistical significance.Post-op complications were deep surgical site infection (n=3), pulmonary embolism (n=1), bleeding (n=5), reoperation (n=3), and 30-day readmission (n=6). ConclusionsConversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss.

Analysis of emergent reoperations after bariatric surgery: an important metric for safe same-day surgery

BackgroundEarly reoperation after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) is a severe adverse event that may increase the risk of perioperative mortality if there is a delay in care. However, it is unclear what proportion of reoperations occur within 24 hours of surgery and who is at greater risk, which may impact the safety of performing safe same-day surgery. ObjectivesTo evaluate the incidence of reoperation in the first 24 hours after primary SG and RYGB. SettingMichigan Bariatric Surgery Collaborative, Ann Arbor, Michigan. MethodsUsing a statewide bariatric surgery data registry, patients undergoing primary SG (n = 49,848) and RYGB (n = 11,267) cases were analyzed. Patients who had a subsequent reoperation were identified and reasons for reoperation were compared between those occurring <24 hours versus >24 hours. In addition, patients who underwent a reoperation <24 hours were compared with patients who underwent primary SG or RYGB and did not experience any complications. ResultsThe overall rate of reoperation was .72% for SG and 2.1% for RYGB. Reoperation <24 hours of index procedure was 32.0% after SG and 24.2%, after gastric bypass, with the most common reason being hemorrhage (86.15%% and 55.4% respectively). Older age, hypertension, liver disease, and longer operative times were associated with reoperation <24 hours after SG, whereas longer operative times were associated with reoperation <24 hours after RYGB. Concurrent hiatal hernia repair was not associated with increased risk. ConclusionsReoperation after primary bariatric surgery is rare but occurs within 24 hours in approximately one third of the cases after SG and one quarter of cases after RYGB. Older patients with significant comorbidities are at increased risk and should be considered poor candidates for same-day surgery given the possibility of an early life-threatening event.