Fewer Recurrences Seen After Robotic Paraesophageal Hernia Repairs

By Scott Baltic

August 31, 2020

NEW YORK (Reuters Health) - Robotic-assisted paraesophageal hernia (PEH) repair appears to be associated with a lower rate of hernia recurrence than is laparoscopic surgery, according to a new study.

"This is the first large series to demonstrate a potential advantage of robotic surgery when performing paraesophageal hernias not only in primary repairs but also recurrent repairs, which are way more complex," Dr. Carlos Galvani, chief of the division of minimally invasive and bariatric surgery at Tulane University School of Medicine, in New Orleans, told Reuters Health by email. Dr. Galvani was not involved in the research.

Not much is known about the long-term outcomes of robotic PEH repair. In the new study, Dr. Michael Awad of Washington University School of Medicine in St. Louis, Missouri, and colleagues followed 233 adults who had undergone the procedure at the center between 2010 and 2014.

The patients' mean age was 67 years, and two-thirds were women; about three-quarters had a type III PEH, the rest type IV or II. A single highly experienced surgeon performed the surgeries using a da Vinci Si or Xi Surgical System.

Mean operative time was 184 minutes and estimated blood loss 34 mL. There were no conversions to an open procedure. The average length of stay was 1.9 days, and one patient required an operation within 30 days.

Five-year follow-up data were available on 145 patients (62%), 9% of whom had a hiatal-hernia recurrence - a rate Dr. Galvani called "remarkable."

As of the five-year point, 91% were satisfied with the results of surgery, and only two patients had undergone re-operation for recurrence. There was a large drop in use of anti-reflux medicine and a significant improvement in scores on the gastroesophageal reflux disease-health-related quality of life (GERD-HRQL) questionnaire, from 25.6 to 4.5.

"Our results demonstrate that robotic PEH repair with an experienced surgical team is a safe and effective alternative to laparoscopic repair with excellent long-term outcomes including a very low recurrence rate," the authors write.

This contrasts with a five-year recurrence rate after laparoscopic surgery of 57%, in a multi-center U.S. study published in 2012, they note.

What drives the new findings isn't completely clear, the authors say, "but we hypothesize that the extensive mediastinal dissection and esophageal mobilization (re-lengthening) facilitated by the robotic approach may be a significant contributing factor."

Dr. Awad told Reuters Health by phone that because a severe PEH (which typically takes decades to develop) results in the thoracic portion of the esophagus taking on a corkscrew-like shape, mobilizing it is an important goal and benefit of robotic hernia repair.

"The take-home point," he added, "is that the robotic approach allows us to make a dramatic impact on recurrence rates."

SOURCE: https://bit.ly/3gjlvqJ Journal of the American College of Surgeons, online August 3, 2020.