Robotic Voluminous Paraesophageal Hernia Repair

A Case Report and Review of the Literature

Nicola Tartaglia; Giovanna Pavone; Alessandra Di Lascia; Fernanda Vovola; Francesca Maddalena; Alberto Fersini; Mario Pacilli; Antonio Ambrosi


J Med Case Reports. 2020;14(25) 

In This Article

Abstract and Introduction


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.


Hiatal hernia is defined as the temporary or permanent migration of a portion or all of the stomach, or other viscera, into the mediastinum via a defect in the diaphragmatic crura, which normally define the esophageal hiatus. This is a very common clinical problem, affecting up to 60% of the adult population.[1] There are four types of hiatal hernias; however, the sliding hiatal hernia (type 1) is the most common and accounts for up to 95% of all hiatal hernias.

Type 1 hiatal hernias solely involve "sliding" of the gastroesophageal (GE) junction (GEJ) into the thoracic cavity. Types 2 to 4 hiatal hernias are true paraesophageal hernias (PEHs) and are classified based on the location of the GEJ as well as what has herniated into the thoracic cavity. A type 2 hiatal hernia has a GEJ in the normal anatomic position, but a portion of the stomach, most often the fundus, has herniated through the hiatus. Type 3, like type 2, has a portion of the stomach that has herniated through the hiatus, but also has an abnormal position of the GEJ in the thoracic cavity. Type 4 has an abnormal GEJ position like types 1 and 3 but another organ, most often a portion of the colon, has herniated into the thoracic cavity.[2]

In the literature, PEH is mostly present among individuals aged 65 to 75-years old.[3–5] It is believed that most patients with PEH are asymptomatic. Symptoms can be caused by obstruction, GE reflux disease (GERD), bleeding, and iron deficiency anemia.

Obstruction at the GEJ or at the level of the pylorus can occur from intermittent twisting of the stomach along its long axis while herniating into the chest. If the GEJ is obstructed, the patient will complain of dysphagia and regurgitation, whereas gastric outlet obstruction produces nausea, vomiting, and epigastric or chest pain.

GERD is more common in sliding hiatal hernia but can occur in PEHs as well. In a series of 95 consecutive patients with GERD, those with a sliding hiatal hernia over 3 cm had a significantly shorter lower esophageal sphincter (LES) and greater reflux on pH monitoring than those with no sliding hiatal hernia or a sliding hiatal hernia < 3 cm.[6] Bleeding from the herniated fundus of the stomach owing to mucosal ulcers, known as Cameron lesions, can produce iron deficiency anemia.

Regardless of the mechanism of action, many patients with PEHs can have other nonspecific symptoms, such as postprandial chest pain, postprandial fullness, and shortness of breath. Patients with nonspecific symptoms can develop strangulation of the stomach from acute gastric volvulus, which constitutes a surgical emergency. In the management of those patients, a nasogastric tube cannot be placed into the stomach because patients retch but cannot vomit.[7]

The treatment for sliding esophageal hernia with mild GE reflux is usually conservative. Surgical treatment is recommended for sliding esophageal hernia refractory to conservative treatment, PEH liable to prolapse, or PEH with ulceration and/or stenosis. In cases of PEH, prolapse may suddenly occur, causing complications such as gastrointestinal necrosis by strangulation, gastric perforation, or massive hemorrhage. A high mortality rate is associated with PEH with complications; therefore, surgical treatment for PEH with or without complications is recommended.[8]

In this article, we present a case report of a 44-year-old woman with voluminous paraesophageal hiatal hernia treated with the robotic approach (Nissen fundoplication).