Studies reporting on the recurrence rate after laparoscopic repair of large hiatal hernias (HH), including anatomical asymptomatic recurrence, are scarce. So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease (GERD) is still obscure. In this prospective study, we analyzed the da Vinci Intuitive Surgical robotic system for antireflux surgery. In August 2012, we set up a pilot study to evaluate the efficacy of laparoscopic telerobotic surgery using the three-arm da Vinci system. Optimal trocar positions, operating and setup times, conversion rate, intraoperative complications, and perioperative morbidity, as well as mortality rate, were analyzed.

1. Robotic-assisted hiatal hernia surgery with the da Vinci
system: A 2-year experience in a single institution

2. Original Article
Robotic-assisted hiatal hernia surgery with the da
Vinci system: A 2-year experience in a single
institution
Arun Prasad a,
*, Ramesh Kumar Aggarwal b
, Abhishek Tiwari c
,
Vachan S. Hukkeri d
a
Sr. Consultant, General Surgery, Indraprastha Apollo Hospital, New Delhi, India
b
DNB Resident, General Surgery, Indraprastha Apollo Hospital, New Delhi, India
c
Sr. Registrar, General Surgery, Indraprastha Apollo Hospital, New Delhi, India
d
DNB Resident, GI Surgery, Indraprastha Apollo Hospital, New Delhi, India
1. Introduction/Background
Robotic-assisted surgery for benign esophageal disease is
described for the treatment of achalasia, epiphrenic diverticu-
la, refractory reflux, paraesophageal hernias, duplication
cysts, and benign esophageal masses, such as leiomyomas.1
While conventional laparoscopic repair for giant hiatal hernias
is considered difficult, robotic technology is likely to result in
an improved postoperative course.2
Morelli et al.3
in their prospective study of 3 years with
robotic da Vinci system included 6 patients for giant hiatal
hernia repair, they showed that robotic approach in hiatal
hernia repair can minimize the surgical trauma and lead to
less anatomical recurrence and better quality of life.
Seetharamaiah R et al.4
in their study concluded that in
giant paraoesophageal hernia repair using robotic system
results in less recurrence but no significant difference in term
of post operative morbidity and operative time.
Draaisma WA et al. 5
in their prospective cohort study on 40
consecutive patients showed that robot-assisted laparoscopic
HH repair proved to be an effective technique with a relatively
low mid-term recurrence rate.
In this study, we measured the post operative outcomes in
term of morbidity, pain and recurrence rate following robotic
hiatal hernia repair.
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 1 1 2 – 1 1 4
a r t i c l e i n f o
Article history:
Received 9 May 2015
Accepted 14 May 2015
Available online 15 June 2015
Keywords:
HH (hiatal hernia)
Robotic da Vinci system
Fundoplication recurrence
Scarring
a b s t r a c t
Studies reporting on the recurrence rate after laparoscopic repair of large hiatal hernias (HH),
including anatomical asymptomatic recurrence, are scarce.
So far, the impact of telematic surgical approach in Gastroesophageal Reflux Disease
(GERD) is still obscure. In this prospective study, we analyzed the da Vinci Intuitive Surgical
robotic system for antireflux surgery. In August 2012, we set up a pilot study to evaluate the
efficacy of laparoscopic telerobotic surgery using the three-arm da Vinci system. Optimal
trocar positions, operating and setup times, conversion rate, intraoperative complications,
and perioperative morbidity, as well as mortality rate, were analyzed.
# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights
reserved.
* Corresponding author. Tel.: +91 11 29871368; fax: +91 9811082425.
E-mail address: surgerytimes@gmail.com (A. Prasad).
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.elsevier.com/locate/apme
http://dx.doi.org/10.1016/j.apme.2015.05.015
0976-0016/# 2015 Indraprastha Medical Corporation Ltd. Published by Elsevier B.V. All rights reserved.

3. 2. Aim
It is a kind of pilot, feasibility study aimed to evaluate the
outcome of robotic hiatal hernia surgery in terms of
postoperative morbidity, (pain, vomiting, and conversion),
hospital stay, and recurrence.
3. Methods
Setting: 750 bedded hospital, 2-year study duration
Design: Prospective pilot observational feasibility study
Tenure: August 2012 to August 2014
Study population: 20 patients undergoing surgery for hiatal
hernia repair robotically (12 females, 8 males) followed for
at least 6 months for the assessment of postoperative pain,
vomiting, postoperative hospital stay, scarring, recurrence
of hernia
Surgery: standard surgical techniques
All the patients underwent for fundoplication procedure
Port placement for robotic hiatal hernia repair.
4. Results
a p o l l o m e d i c i n e 1 2 ( 2 0 1 5 ) 1 1 2 – 1 1 4 113

4. Twenty patients with giant hiatal hernias underwent robotic
repair using the da Vinci surgical system. The mean operative
time was 90 min. The mean hospital stay was 4 days. No
patients required reoperation for disease recurrence, and
nearly all claimed the absence of postoperative symptoms.
This offers several potential benefits, including significantly
less pain, less blood loss, less risk of infection, less scarring, and
shorter hospital stay. The operating team experienced the
support of the robotic system as beneficial, especially in the
dissection of the hernia sac and extensive crural repair, quicker
recovery time, and better clinical outcomes in many cases.
5. Conclusion
Robotic approaches can minimize surgical trauma in patients
with giant hiatal hernias, and result in favourable outcomes in
terms of anatomical recurrence and quality of life. With the
availability of the da Vinci system, all the patients with giant
hiatal hernias can be offered a minimally invasive surgical
option. However, larger series with longer follow-up are
necessary to further substantiate our results.
Conflicts of interest
The authors have none to declare.
Acknowledgements
We are thankful to our nursing staff for their selfless patient
care and to our fellow doctors who helped us perform this
study.
r e f e r e n c e s
1. Hanna JM, Onaitis MW. Robotic benign esophageal
procedures. Thorac Surg Clin. 2014;24(May (2)):223–229. http://
dx.doi.org/10.1016/j.thorsurg.2014.02.004. vii.
2. Gehrig T, Mehrabi A, Fischer L, et al. Robotic-assisted
paraesophageal hernia repair – a case-control study.
Langenbecks Arch Surg. 2013;398(June (5)):691–696. http://dx.
doi.org/10.1007/s00423-012-0982-0 [Epub 2012 Jul 31].
3. Morelli L, Guadagni S, Mariniello MD, et al. Robotic giant
hiatal hernia repair: 3 year prospective evaluation and review
of the literature. Int J Med Robot. 2015;11(March (1)):1–7. http://
dx.doi.org/10.1002/rcs.1595 [Epub 2014 May 28].
4. Seetharamaiah R, Romero RJ, Kosanovic R, et al. Robotic
repair of giant paraesophageal hernias. JSLS. 2013;17(October–
December (4)):570–577.
5. Draaisma WA, Gooszen HG, Consten EC, Broeders IA. Mid-
term results of robot-assisted laparoscopic repair of large
hiatal hernia: a symptomatic and radiological prospective
cohort study. Surg Technol Int. 2008;17:165–170.
Scarring is very minimal, as port size maximum incision is
12 mm in comparison to 7–8 in. in open surgery.
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