Skip to main content
SpringerLink
Log in

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

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD (2013) Guidelines for the management of hiatal hernia. Surg Endosc 27:4409–4428. https://doi.org/10.1007/s00464-013-3173-3

    Article  PubMed  Google Scholar 

  2. Hanly EJ, Talamini MA (2004) Robotic abdominal surgery. Am J Surg 188:19S-26S. https://doi.org/10.1016/j.amjsurg.2004.08.020

    Article  PubMed  Google Scholar 

  3. Braumann C, Jacobi CA, Menenakos C, Ismail M, Rueckert JC, Mueller JM (2008) Robotic-assisted laparoscopic and thoracoscopic surgery with the Da Vinci system: A 4-year experience in a single institution. Surg Laparosc Endosc Percutan Tech 18:260–266. https://doi.org/10.1097/SLE.0b013e31816f85e5

    Article  PubMed  Google Scholar 

  4. Broeders IA (2014) Robotics: the next step. Best Pract Res Clin Gastroenterol 28:225–232. https://doi.org/10.1016/j.bpg.2013.12.001

    Article  PubMed  Google Scholar 

  5. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, Schuchert MJ (2010) Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 139:395–404. https://doi.org/10.1016/j.jtcvs.2009.10.005

    Article  PubMed  Google Scholar 

  6. Yano F, Stadlhuber RJ, Tsuboi K, Gerhardt J, Filipi CJ, Mittal SK (2009) Outcomes of surgical treatment of intrathoracic stomach. Dis Esophagus 22(3):284–288. https://doi.org/10.1111/j.1442-2050.2008.00919.x

    Article  CAS  PubMed  Google Scholar 

  7. Mertens AC, Tolboom RC, Zavrtanik H, Draaisma WA, Broeders IA (2019) Morbidity and mortality in complex robot-assisted hiatal hernia surgery: 7-year experience in a high-volume center. Surg Endosc 33:2152–2161. https://doi.org/10.1007/s00464-018-6494-4

    Article  PubMed  Google Scholar 

  8. Gehrig TA, Mehrabi L, Fischer H, Kenngott U, Hinz C, Gutt N, Müller-Stich BP (2013) Robotic-assisted paraesophageal hernia repair - a case-control study. Langenbecks Arch Surg 398:691–696. https://doi.org/10.1007/s00423-012-0982-0

    Article  PubMed  Google Scholar 

  9. Tolboom RC, Draaisma WA, Broeders IA (2016) Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study. J Robot Surg 10:33–39. https://doi.org/10.1007/s11701-016-0558-z

    Article  PubMed  PubMed Central  Google Scholar 

  10. Falkenback D, Lehane CW, Lord RVN (2015) Robot-assisted oesophageal and gastric surgery for benign disease: antireflux operations and Heller’s myotomy. ANZ J Surg 85:113–120. https://doi.org/10.1111/ans.12731

    Article  PubMed  Google Scholar 

  11. Galvani CA, Loebl H, Osuchukwu O, Samamé J, Apel MA, Ghaderi I (2016) Robotic-assisted paraesophageal hernia repair: initial experience at a single institution”. J Laparoendosc Adv Surg Tech A 26:290–295. https://doi.org/10.1089/lap.2016.0096

    Article  PubMed  Google Scholar 

  12. Brenkman HJF, Parry K, Van Hillegersberg R, Ruurda JP (2016) Robot-assisted hiatal hernia repair: promising anatomical and functional results. J Laparoendosc Adv Surg Tech A 26(6):465–469. https://doi.org/10.1007/s00464-016-4767-3

    Article  PubMed  Google Scholar 

  13. Müller-Stich BP, Reiter MA, Mehrabi A, Wente MN, Fischer L, Köninger J, Gutt CN (2009) No relevant difference in quality of life and functional outcome at 12 months’ follow-up-a randomised controlled trial comparing robot-assisted versus conventional laparoscopic Nissen fundoplication. Langenbecks Arch Surg 394:441. https://doi.org/10.1007/s00423-008-0446-8

    Article  PubMed  Google Scholar 

  14. Ruurda JP, Werner A, Draaisma WA, Van Hillegersberg R, Borel Rinkes IHM, Gooszen HG, Lucas WM, Janssen LVM, Rogier KJ, Simmermacher RKJ, Broeders IA (2005) Robot-assisted endoscopic surgery: a four-year single-center experience. Dig Surg 22:313–320. https://doi.org/10.1159/000088628

    Article  PubMed  Google Scholar 

  15. Draaisma WA, Gooszen HG, Consten ECJ, Broeders IA (2008) Mid-term results of robot-assisted laparoscopic repair of large hiatal hernia: a symptomatic and radiological prospective cohort study. Surg Technol Int 17:165–170

    PubMed  Google Scholar 

  16. Hartmann J, Jacobi CA, Menenakos C, Ismail M (2008) Braumann C (2008) Surgical treatment of gastroesophageal reflux disease and upside-down stomach using the Da Vinci robotic system. A prospective study. J Gastrointest Surg 12(3):504–509. https://doi.org/10.1007/s11605-007-0400-z

    Article  PubMed  Google Scholar 

  17. Prassas D, Rolfs TM, Schumacher FJ (2015) Laparoscopic repair of giant hiatal hernia. A single center experience. Int J Surg 20:149–152. https://doi.org/10.1016/j.ijsu.2015.06.067

    Article  PubMed  Google Scholar 

  18. Sakran N, Nevo H, Dar R, Raziel A, Hershko D (2017) Laparoscopic repair of a large paraesophageal hernia with migration of the stomach into the mediastinum creating an upside-down stomach. Case Rep Surg 2017:7428195. https://doi.org/10.1155/2017/7428195

    Article  PubMed  PubMed Central  Google Scholar 

  19. Soliman BG, Nguyen DT, Chan EY, Chihara RK, Meisenbach LM, Graviss EA, Kim MP (2020) Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair. Surg Endosc 34:2495–2502. https://doi.org/10.1007/s00464-019-07055-8

    Article  PubMed  Google Scholar 

  20. Velanovich V (2007) The development of the GERD-HRQL symptom severity instrument. Dis Esophagus 20:130–134. https://doi.org/10.1111/j.1442-2050.2007.00658x

    Article  CAS  PubMed  Google Scholar 

  21. Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications. Ann Surg 240:205–213. https://doi.org/10.1097/01.sla.0000133083.54934ae

    Article  PubMed  PubMed Central  Google Scholar 

  22. Team, R Core (2016) R: A language and environment for statistical computing. R Foundation for statistical computing

  23. Müller-Stich BP, Kenngott HG, Gondan M, Stock C, Linke GR, Fritz F, Nickel F (2015) Use of mesh in laparoscopic paraesophageal hernia repair: a meta-analysis and risk-benefit analysis. PLoS ONE. https://doi.org/10.1371/journal.pone.0139547

    Article  PubMed  PubMed Central  Google Scholar 

  24. Tam V, Winger DG, Nason KS (2016) A Systematic review and meta-analysis of mesh vs. suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. https://doi.org/10.1016/j.amjsurg.2015.07.007

    Article  PubMed  Google Scholar 

  25. MacDuff A, Arnold A, Harvey J (2010) Management of spontaneous pneumothorax: british thoracic society pleural disease Guideline 2010. Thorax. https://doi.org/10.1136/thx.2010.136986

    Article  PubMed  Google Scholar 

  26. Schnell J, Beer M, Eggeling S, Gesierich W, Gottlieb J, Herth FJF, Hofmann H-S, Jany B, Kreuter M, Ley-Zaporozhan J, Scheubel R, Walles T, Wiesemann S, Worth H, Stoelben E (2019) Management of spontaneous pneumothorax and post-interventional pneumothorax: german S3 guideline. Respiration 97:370–402

    Article  Google Scholar 

  27. Taenzer AH, Perreard IM, MacKenzie T, McGrath SP (2018) Characteristics of Desaturation and Respiratory Rate in Postoperative Patients Breathing Room Air Versus Supplemental Oxygen: Are They Different? Anesth Analg. https://doi.org/10.1213/ANE.0000000000002765

    Article  PubMed  Google Scholar 

  28. Sarkaria IS, Latif MJ, Bianco VJ, Bains MS, Rusch VW, Jones DR, Rizk NP (2017) Early operative outcomes and learning curve of robotic assisted giant paraesophageal hernia repair. Int J Med Robot. https://doi.org/10.1002/rcs.1730

    Article  PubMed  Google Scholar 

  29. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA (2012) Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials. Surg Laparosc Endosc Percutan Tech. https://doi.org/10.1097/SLE.0b013e3182747ac2

    Article  PubMed  Google Scholar 

  30. Furnée E, Hazebroek E (2013) Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature. Surg Endosc. https://doi.org/10.1007/s00464-013-3036-y

    Article  PubMed  Google Scholar 

  31. Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD, Aly A, Gan S, Game PA, Jamieson GG (2015) Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial. Ann Surg. https://doi.org/10.1097/SLA.0000000000000842

    Article  PubMed  Google Scholar 

  32. Watson DI, Thompson SK, Devitt PG, Aly A, Irvine T, Woods SD, Gan S, Game PA, Jamieson GG (2019) Five year follow-up of a randomized controlled trial of laparoscopic repair of very large hiatus hernia with sutures versus absorbable versus nonabsorbable mesh. Ann Surg. https://doi.org/10.1097/SLA.0000000000003734

    Article  PubMed  Google Scholar 

  33. Müller-Stich BP, Reiter MA, Wente MN, Bintintan VV, Köninger J, Büchler MW, Gutt CN (2007) Robot-assisted versus conventional laparoscopic fundoplication: short-term outcome of a pilot randomized controlled trial. Surg Endosc 21:1800–1805. https://doi.org/10.1007/s00464-007-9268-y

    Article  PubMed  Google Scholar 

  34. Frazzoni M, Conigliaro R, Colli G, Melotti G (2012) Conventional versus robot-assisted laparoscopic Nissen fundoplication: a comparison of postoperative acid reflux parameters. Surg Endosc 26:1675–1681. https://doi.org/10.1007/s00464-011-2091-5

    Article  PubMed  Google Scholar 

  35. Castelijns PS, Ponten JE, Bouvy ND, Smulders JF, Van De Poll MC (2018) Intrathoracic stomach in hiatal hernia: the role of laparoscopic repair. Minerva Chir 73:64–76. https://doi.org/10.23736/S0026-4733.17.07574-5

    Article  PubMed  Google Scholar 

  36. Shrestha AK, Joshi M, DeBono L, Naeem K, Basu S (2019) Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience. Hernia. https://doi.org/10.1007/s10029-019-01888-x

    Article  PubMed  Google Scholar 

  37. Owen B, Simorov A, Siref A, Shostrom V, Oleynikov D (2014) How does robotic anti-reflux surgery compare with traditional open and laparoscopic techniques: a cost and outcomes analysis. Surg Endosc 28:1686–1690. https://doi.org/10.1007/s00464-013-3372-y

    Article  PubMed  Google Scholar 

Download references

Author contributions

All authors have contributed to the article. AW and FN wrote the main manuscript text, created tables and figures and collected most data. LF, RS, LK and DD helped keeping data files updated, performed limited data analysis, and reviewed the manuscript. Most of reviewing, coordination, rewriting and data analyses was achieved by FA and MB. MF, DS and RP are responsible for study design and coordination and reviewed the manuscript.

Funding

This study was funded by institutional means.

Author information

Author notes

  1. Alexander Wilhelm and Fabio Nocera have contributed equally and share first authorship.

  2. Fiorenzo V. Angehrn and Martin Bolli have contributed equally and share last authorship.

Authors and Affiliations

  1. Clarunis, Department of Visceral Surgery, University Center for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Postfach, 4002, Basel, Switzerland

    Alexander Wilhelm, Fabio Nocera, Romano Schneider, Diana L. Daume, Lana Fourie, Daniel Steinemann, Markus von Flüe, Ralph Peterli, Fiorenzo V. Angehrn & Martin Bolli

  2. Department of Surgery, University Hospital Basel, Basel, Switzerland

    Luca Koechlin

Authors
  1. Alexander Wilhelm
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fabio Nocera
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Romano Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Luca Koechlin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Diana L. Daume
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lana Fourie
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Daniel Steinemann
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Markus von Flüe
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Ralph Peterli
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Fiorenzo V. Angehrn
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Martin Bolli
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alexander Wilhelm.

Ethics declarations

Disclosures

Alexander Wilhelm, Fabio Nocera, Romano Schneider, Luca Koechlin, Diana L Daume, Lana Fourie, Daniel Steinemann, Markus von Flüe, Ralph Peterli, Fiorenzo V Angehrn, Martin Bolli have no conflict of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Wilhelm, A., Nocera, F., Schneider, R. et al. Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): a prospective comparative single center study. Surg Endosc 36, 480–488 (2022). https://doi.org/10.1007/s00464-021-08307-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-021-08307-2

Keywords

Search

Navigation