Early operative outcomes and learning curve of robotic assisted giant paraesophageal hernia repair

Determining the learning curve of minimally invasive antireflux surgery: systematic review, meta-analysis, and meta-regression

The rapid uptake of minimally invasive antireflux surgery has led to interest in learning curves for this procedure. This study ascertains the learning curve in laparoscopic and robotic-assisted antireflux surgery. A systematic review of the literature pertaining to learning curves in minimally invasive fundoplication with or without hiatal hernia repair was performed using PubMed, Medline, Embase, Web of Science, and Cochrane Library databases. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase. Twenty-five studies met the eligibility criteria. A meta-regression analysis was performed to quantitatively investigate the trend of number of cases required to achieve surgical proficiency from 1996 to present day. Using a mixed-effects negative binomial regression model, the predicted learning curve for laparoscopic and robotic-assisted antireflux surgery was found to be 24.7 and 31.1 cases, respectively. The meta-analysis determined that surgeons in their learning phase may experience a moderately increased rate of conversion to open procedure (odds ratio [OR] 2.44, 95% confidence interval [CI] 1.28, 4.64), as well as a slightly increased rate of intraoperative complications (OR 1.60; 95% CI 1.08, 2.38), postoperative complications (OR 1.98; 95% CI 1.36, 2.87), and needing reintervention (OR 1.64; 95% CI 1.16, 2.34). This study provides an insight into the expected caseload to be competent in performing antireflux surgery. The discrepancy between outcomes during and after the learning curve for antireflux surgery suggests a need for close proctorship for learning surgeons.

Emergency robotic surgery: the experience of a single center and review of the literature

BACKGROUNDS

Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.

METHODS

We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).

RESULTS

36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.

CONCLUSIONS

Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

Association of Upper GI Surgery of Great Britain and Ireland (AUGIS) Delphi consensus recommendations on the adoption of robotic upper GI surgery

BACKGROUND

The adoption of robotic platforms in upper gastrointestinal (GI) surgery is expanding rapidly. The absence of centralised guidance and governance in adoption of new surgical technologies may lead to an increased risk of patient harm.

METHODS

Surgeon stakeholders participated in a Delphi consensus process following a national open-invitation in-person meeting on the adoption of robotic upper GI surgery. Consensus agreement was deemed met if >80% agreement was achieved.

RESULTS

Following two rounds of Delphi voting, 25 statements were agreed on covering the training process, governance and good practice for surgeons' adoption in upper GI surgery. One statement failed to achieve consensus.

CONCLUSIONS

These recommendations are intended to support surgeons, patients and health systems in the adoption of robotics in upper GI surgery.

Tackling complex thoracic surgical operations with robotic solutions: a narrative review

Background and Objective

The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions.

Methods

Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria.

Key Content and Findings

The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates.

Conclusions

The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.

The Belsey Mark IV procedure in the era of minimally invasive antireflux surgery

BACKGROUND

Different surgical techniques exist in the treatment of giant and complex hiatal hernia. The aim of this study was to identify the role of the Belsey Mark IV (BMIV) antireflux procedure in the era of minimally invasive techniques.

METHODS

A single-center, retrospective cohort study was conducted. All patients who underwent an elective BMIV procedure aged 18 years or older, during a 15-year period (January 1, 2002 until December 31, 2016), were included. Demographics, pre-, per- and postoperative data were analyzed. Three groups were compared. Group A: BMIV as first procedure-group B: BMIV as a second procedure (first redo intervention)-group C: patients who had two or more previous antireflux interventions.

RESULTS

A total of 216 patients were included for analysis (group A n = 127; group B n = 51; group C n = 38). Median follow-up in groups A, B and C was 28, 48 and 56 months, respectively. Patients in group A were older and had a higher American Society of Anesthesiologists score compared to groups B and C. There was zero mortality in all groups. The severe complication rate of 7.9% in group A was higher compared with the 2.9% in group B and 3.9% in group C. Long-term outcome showed true recurrence, defined as both radiographic recurrence as well as associated symptoms, in 9.5% of cases in group A, 24.5% in group B and 44.7% in group C.

CONCLUSIONS

The BMIV procedure is a safe procedure with good results, moreover in the aging and comorbid patient with primary repair of a giant hiatal hernia.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis

Purpose

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence.

Methods

A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time.

Results

Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates.

Conclusion

Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

Economic evaluation of robotic and laparoscopic paraesophageal hernia repair

BACKGROUND

Robotic approach in paraesophageal hernia (PEH) repair may improve outcomes over laparoscopic approach, though at additional cost. This study aimed to compare cost-effectiveness of robotic and laparoscopic PEH repair.

METHODS

A decision tree was created analyzing cost-effectiveness of robotic and laparoscopic PEH repair. Costs were obtained from 2021 Medicare data and were accumulated within 60 months after surgery. Effectiveness was measured in quality-adjusted life-years (QALYs). Branch-point probabilities and costs of robotic surgery consumables were obtained from published literature. The primary outcome of interest was incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed. A secondary analysis including attributable capital and maintenance costs of robotic surgery was conducted as well.

RESULTS

Laparoscopic repair yielded 3.660 QALYs at $35,843.82. Robotic repair yielded 3.661 QALYs at $36,342.57, with an ICER of $779,488.62/QALY. Robotic repair was favored when rates of open conversion and symptom recurrence were low, or with reduced cost of robotic instruments. A probabilistic sensitivity analysis favored laparoscopic repair in 100% of simulations. When accounting for costs of robotic technology, robotic approach was preferred only in unrealistic clinical scenarios.

CONCLUSIONS

Laparoscopic repair is likely more cost-effective for most institutions, though results were relatively similar. With experienced surgeons who surpass the initial learning curve, robotic surgery may improve outcomes enough to be cost-effective, but only when excluding capital and maintenance fees.

[Bile duct repair after complete intersection]

OBJECTIVE

To determine the training period for imposing hepaticojejunostomy for bile duct repair.

MATERIAL AND METHODS

Reconstructive surgery on the bile ducts was performed in 53 patients. We analyzed the learning curves based on the incidence of anastomotic leakage after hepaticojejunostomy.

RESULTS

The learning curve has a downward nature. The number of anastomotic failures decreases by 2 times after 42 procedures. Surgeon had to perform 39-42 operations to reduce the incidence of this complication.

CONCLUSION

Treatment of patients with iatrogenic intersections of the bile ducts should be provided in appropriate hospitals.

Robotic-assisted hiatal hernia repair and pulmonary embolism: an institution-based retrospective cohort study

Hiatal hernia (HH) is an abnormal protrusion of components of the abdominal viscera through the esophageal hiatus. The laparoscopic approach is the gold standard for repair with the robotic technique now gaining wide acceptance. Pulmonary embolism (PE) is a well-known post-operative complication but its incidence following robotically assisted HH repairs is not well known. This study provides a descriptive analysis of three patients who developed PE after robotic repairs of their HHs. The incidence of PE in the studied cohort was 2.7% (3 of 112) with a male preponderance (66.7%). The mean age of the patients was 55.3 years with a mean BMI of 32.2 kg/m². The average duration of surgery was 4.2 h with sizes of the diaphragmatic defects ranging from 3 to 6 cm. Confirmatory PE diagnosis was made with a chest CT angiogram and the mean length of hospital stay was 4 days. PE although rare, is a preventable cause of in-patient mortality and morbidity with implications on healthcare costs and hospital resource use. The Caprini model provides a guide to pre-operative patient risk stratification and PE prevention, and the patients in this study were in the moderate to high-risk groups. Risk factors common to all patients were: age > 40 years, BMI > 30 kg/m² and duration of surgery > 2 h with one of the patients having a previous history of PE. There are no established PE chemoprophylaxis guidelines for robotic HH repairs and in this cohort, heparin was commenced 6-8 h post-operatively. Thus, there is a need for a consensus chemoprophylaxis guideline in this subset of surgical patients. PE following robotic HH repair is associated with prolonged hospital stay and increased healthcare costs. Guidelines for effective pre-operative chemoprophylaxis for these repairs are needed to optimize patient outcomes.

State-Level Examination of Clinical Outcomes and Costs for Robotic and Laparoscopic Approach to Diaphragmatic Hernia Repair

BACKGROUND

Published studies evaluating the effect of robotic assistance on clinical outcomes and costs of care in diaphragmatic hernia repair (DHR) have been limited.

STUDY DESIGN

The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing transabdominal DHR between 2011 and 2018 and associated inpatient and outpatient encounters within 12 months after the index operation. Patients undergoing robotic DHR were 1:1:1 propensity score-matched for age, sex, race, Elixhauser comorbidity score, case priority, payer, and facility volume with patients undergoing open and laparoscopic DHR.

RESULTS

There were 5,962 patients (67.3%) who underwent laparoscopic DHR, 1,520 (17.2%) who underwent open DHR, and 1,376 (15.5%) who underwent robotic DHR. On comparison of matched cohorts, median index length of stay (3 days; interquartile range [IQR] 2 to 5 days vs 2 days; IQR 1 to 4 days; p < 0.001) and index hospitalization costs ($17,236; IQR $13,231 to $22,183 vs $12,087; IQR $8,881 to $17,439; p < 0.001) for robotic DHR were greater than for laparoscopic DHR. Median length of stay for open DHR (6 days; IQR 4 to 10 days) was longer than that for both laparoscopic and robotic DHR. Median index hospitalization costs for open DHR ($16,470; IQR $11,152 to $23,768) were greater than those for laparoscopic DHR, but less than those for robotic DHR. There were no significant differences between cohorts in the overall rate of post-index care.

CONCLUSIONS

Laparoscopic DHR is the most cost-effective approach to DHR. Robotic assistance provides clinical outcomes comparable with laparoscopic DHR, but is associated with increased index cost.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): a prospective comparative single center study

BACKGROUND

Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).

METHODS

All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire.

RESULTS

A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.

CONCLUSION

While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

Patient reported outcomes (PROs) after minimally invasive and open esophagectomy

Esophagectomy for esophageal malignancies remains an operation with significant potential morbidity and mortality. However, surgical outcomes continue to improve over time and focus has shifted toward not just good outcomes, but quality of life post operatively. Patient reported outcomes (PROs) focus of quality of life measures via validated patient surveys has increasingly become a significant focus. While PROs do have their limitations, they represent a glimpse into the symptomatology, quality of life, and well-being of a patient undergoing a procedure with inherent morbidity. Working to improve outcomes from the perspective of the patient is not a new concept, but has becoming increasingly relevant as surgical quality for all procedures improves. The optimal approach to esophagectomy is controversial. Minimally invasive approaches attempt to avoid laparotomy and thoracotomy with the thought of improving post-operative quality of life by mitigating complications related to those open surgical approaches. The data in favor of laparoscopy and thoracoscopy is quite strong and multiple randomized controlled trials exist in this realm supporting minimally invasive approaches with regards to quality of life outcomes and more rapid return to patient’s preoperative baseline. The data in favor of a robotic approach for esophagectomy is not quite as robust, but more studies show that these approaches mirror the benefits of the laparoscopic and thoracoscopic approaches without robotic assistance.

Robotic Versus Laparoscopic Approach to Hiatal Hernia Repair: Results After 7 Years of Robotic Experience

INTRODUCTION

Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs.

METHODS

A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software.

RESULTS

Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001).

DISCUSSION

Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.

Robotic voluminous paraesophageal hernia repair: a case report and review of the literature

Background

The treatment for sliding esophageal hernia with mild gastroesophageal reflux is usually conservative, but surgical treatment is recommended for refractory sliding esophageal hernia, paraesophageal hernia liable to prolapse, or paraesophageal hernia with ulceration and/or stenosis. Robotic surgery overcomes laparoscopic pitfalls by providing steady-state three-dimensional visualization, augmented dexterity with endo-wrist movements, and superior ergonomics for the surgeon.

Case presentation

To investigate robotic paraesophageal hernia repair, a literature search was conducted using PubMed with the following key words: mini invasive surgery, robotic surgery, hiatal hernia, and Nissen fundoplication. We present the case of a 44-year-old Italian woman with a 20-year history of gastroesophageal reflux disease refractory to medical treatment, who underwent robotic Nissen fundoplication. In our center, we use the da Vinci® Xi™ Surgical System, which is an advanced tool for minimally invasive surgery.

Conclusions

Various reports published in the literature suggested that the robot-assisted approach was effective and was associated with very low postoperative morbidity and was accompanied by satisfactory symptomatic and anatomical radiological outcomes during a follow-up period.

The robotic approach to paraesophageal repair is safe and effective with low complication rates. With increased experience, the operative time, length of stay, and complications decrease without compromising surgical principles.

Safety of robotic assisted laparoscopic recurrent paraesophageal hernia repair: insights from a large single institution experience

BACKGROUND

Laparoscopic repair of recurrent as opposed to primary paraesophageal hernias (PEHs) are historically associated with increased peri-operative complication rates, worsened outcomes, and increased conversion rates. The robotic platform may aid surgeons in these complex revision procedures. The aim of this study was to compare the outcomes of patients undergoing robotic assisted laparoscopic (RAL) repair of recurrent as opposed to primary PEHs.

METHODS

Patients undergoing RAL primary and recurrent PEH repairs from 2009 to 2017 at a single institution were reviewed. Demographics, use of mesh, estimated blood loss, intra-operative complications, conversion rates, operative time, rates of esophageal/gastric injury, hospital length of stay, re-admission/re-operation rates, recurrence, dysphagia, gas bloat, and pre- and post-operative proton pump inhibitor (PPI) use were analyzed. Analysis was accomplished using Chi-square test/Fischer's exact test for categorical variables and the Mann-Whitney U test for continuous variables.

RESULTS

There were 298 patients who underwent RAL PEH repairs (247 primary, 51 recurrent). They were followed for a median (interquartile range) of 120 (44, 470) days. There were no significant differences in baseline demographics between groups. Patients in the recurrent PEH group had longer operative times, increased use of mesh, and increased length of hospital stay. They were also less likely to undergo fundoplication. There were no significant differences in estimated blood loss, incidence of intra-operative complications, re-admission rates, incidence of post-operative dysphagia and gas bloat, and incidence of post-operative PPI use. There were no conversions to open operative intervention or gastric/esophageal injury/leaks.

CONCLUSIONS

Although repair of recurrent PEHs are historically associated with worse outcomes, in this series, RAL recurrent PEH repairs have similar peri-operative and post-operative outcomes as compared to primary PEH repairs. Whether this is secondary to the potential advantages afforded by the robotic platform deserves further study.

Systematic review of learning curves in robot-assisted surgery

Background

Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery.

Methods

MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients.

Results

Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology.

Conclusion

Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.

Surgical Anatomy of Paraesophageal Hernias

Paraesophageal hernia represents a complex surgical problem involving significant distortion of the anatomy and function of the esophagus, stomach, gastroesophageal junction, mediastinum, lungs, and heart. Surgeons operating in the area must have deep understanding of the normal anatomy and pathologic derangements in patients with paraesophageal hernias. This article describes the normal anatomy and anatomic abnormalities in application to the various approaches used in the surgical repair of a paraesophageal hernia.

Surgical Techniques for Robotically-Assisted Laparoscopic Paraesophageal Hernia Repair

The surgical approach to giant paraesophageal hernia repair has evolved considerably, from an open approach to minimally invasive approaches. Laparoscopic and robotic-assisted approaches to giant paraesophageal hernia have been considered safe and are associated with less morbidity and mortality. Limited data exist comparing the efficacy between laparoscopic and robotic-assisted giant paraesophageal hernia repairs, but the benefits of robotic surgery include superior optics and freedom of motion, thus allowing surgeons to accomplish the key points in a successful repair without compromising patient outcomes.

Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair

BACKGROUND

We postulated that the use of robotics may improve outcomes in hiatal hernia repair.

METHODS

We performed a retrospective analysis of a prospectively collected Society of Thoracic Surgery database at a single institution of patients who underwent elective hiatal hernia repair from 2012 to 2017 using either laparoscopy or the da Vinci Xi robot. We compared patient characteristics and outcomes and then performed univariate and multivariate logistic regression modeling to determine the factors associated with postoperative morbidity.

RESULTS

There were 293 consecutive patients who underwent elective hiatal hernia repair using either a laparoscopic (n = 151) or a robotic (n = 142) technique. There were no significant differences in age, gender, BMI, smoking history, presence of comorbidity, or hiatal hernia type. Seventy percent of the cases were a repair of either type III or type IV hiatal hernia. There were significantly higher ASA III and IV (7.9% vs. 4.2%, P = 0.03), higher Toupet fundoplication (83.4% vs. 44.4%, P < 0.001), and lower redo-repair (7.3% vs. 20.4%, P = 0.001) in the laparoscopic group compared to the robotic group. The hospital length of stay was significantly shorter (1.3 ± 1.8 vs. 1.8 ± 1.5 days, P = 0.003) and there were significantly lower rates of complications (6.3 vs. 19.2%, P = 0.001) after robotic compared to laparoscopic hiatal hernia repair. There was no difference in readmission rate and mortality. Multiple logistic regression analysis showed that older age and laparoscopic technique were associated with higher complications after surgery.

CONCLUSION

The use of the Da Vinci Xi robot in our institution was associated with improved outcomes compared to laparoscopic hiatal hernia repair despite a higher incidence of re-operative cases in the robotic group. Thus, short-term outcomes of Da Vinci Xi robot-assisted hiatal hernia repair are not inferior to laparoscopic hiatal hernia repair. Further studies are needed to determine if Da Vinci Xi robot provides superior short-term and long-term outcome in treatment of symptomatic hiatal hernia.