Evaluation of robot-assisted laparoscopic versus conventional laparoscopic hiatal hernia repair in children

Laparoscopic approach is the gold standard for repairing hiatal hernia (HH). Robotic technology is now widely accepted, but it is rarely used in children with HH. Our aim was to evaluate the clinical effect of robot-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS) in the treatment of HH in children. A retrospective study was carried out in patients undergoing elective robot-assisted laparoscopic or conventional laparoscopic HH repair at a tertiary academic hospital from January 2020 to December 2022, and patients who met the inclusion criteria were included in this study. We compared the characteristics and clinical results of patients to understand the effects of the two surgical methods. Forty-six patients (CLS, group 1, n = 25; RALS, group 2, n = 21) met the inclusion criteria. All operations were performed by one experienced pediatric surgeon. In this study, no significant differences were found in terms of gender, age, weight, size of HH, total operation times, the effective operation time (excluding setup time) and complications between group 1 and group 2. (P = 0.979, P = 0.438, P = 0.265, P = 0.800, P = 0.122, P = 0.427 and P = 0.478, respectively). However, the intraoperative bleeding, the intensive care unit (ICU) admission, postoperative hospital length of stay (LOS) and postoperative fasting time were significantly less for RALS (P = 0.016, P = 0.040, P = 0.035 and P = 0.025, respectively). Meanwhile, the overall charges were significantly higher in group 2 (P < 0.01). Despite higher charges for robotic-assisted HH repair, it is a safe and reliable alternative to CLS and was associated with better outcomes in children.

Laparoscopic total left-sided surgical approach versus traditional bilateral surgical approach for treating hiatal hernia: a study protocol for a randomized controlled trial

Background

In China, guidelines for the treatment of hiatal hernia (HH) are lacking. Furthermore, efficacy and safety assessments of surgical approaches for HH and for the protection of the vagus nerve and organ function are needed. Therefore, the present clinical trial is being conducted to establish the normative treatment for HH.

Methods

The current trial is an ongoing, single-center, randomized controlled trial of patients with HH. The total sample size required for the trial (July 2020–December 2023) is approximately 114 patients. Patients will be randomly assigned to either an experimental group (total left-sided surgical approach; TLSA) or a control group (traditional bilateral surgical approach; TBSA) at a ratio of 1:1 using the block randomization method. We will use case report forms (CRFs) and electronic data capture (EDC) systems to obtain demographic information, preoperative laboratory tests, auxiliary examination results, operation information, and postoperative condition. The patients will be followed up for 3 years after surgery. The primary endpoint is the gastrointestinal quality-of-life index (GIQLI) at 1 year. The secondary endpoints include an efficacy evaluation index [consisting of the incidence of gallstones and gastric emptying disorders, gastrointestinal function recovery time, visual analog scale (VAS) scores, objective evaluation of postoperative indices, and surgical information] and a safety evaluation index (consisting of the incidence of postoperative complications, the 30-day postoperative mortality rate, and the HH recurrence rate at 1 and 3 years after surgery).

Discussion

TLSA can protect the normal physiological function of organs to a certain extent by protecting the vagus nerve from injury, and has satisfactory short- and long-term efficacy. There is no significant difference in the incidence of postoperative complications and surgical safety between TLSA and TBSA. Our findings will facilitate clinical decision-making for HH and improve the life quality of patients.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2000034028 (registration date: June 21, 2020).

Laparoscopic repair of giant hiatal hernia for elderly patients

Background

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.

Methods

From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age <75). Interrupted non-absorbable suture was applied for crus closure and as an additional reinforcement, the mesh was fixed with absorbable tacks or medical glue. Procedure-related complications, score-based variation tendency of symptoms, gastrointestinal quality of life index (GIQLI), mortality, recurrence rate, hemoglobin, and the use of PPI were investigated.

Results

All patients underwent the procedure uneventfully. Dor fundoplication was used in 39 patients (62.9%) in the elderly group and 44 (50.0%) in the younger group and no case was converted to open. While the elderly group had a significantly higher percentage of ASA Class level 3 and cardiovascular and cerebrovascular diseases as compared to the younger group, the two groups had similar operative times, intraoperative blood loss, and percentage of intrathoracic stomach. Elderly group patients tended to have higher perioperative complications including pneumonia (3.2%) and atelectasis (3.2%) without statistical significance, as well as transfer to the intensive care unit compared, to younger patients (9.7% vs. 3.2%; P=0.144). The mean post-operative hospital stay was also significantly shorter in the younger group (2.8 days) compared with the elderly group (3.5 days; P=0.001). There was no mortality, recurrence, mesh-related complications such as visceral erosion, adhesion, or severe dysphagia during follow up in the two groups, and both groups demonstrated significant improvement in GIQLI scores and hemoglobin. The percentage of patients who needed PPI was also reduced in both groups.

Conclusions

Laparoscopic mesh repair of giant hiatal hernia for elderly patients is safe and effective when performed at experienced centers.

Hiatal hernia after robotic-assisted coronary artery bypass graft surgery

Background

The aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery.

Methods

We reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH.

Results

We found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4-9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2-64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10-8.43), P=0.033.

Conclusions

RA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.