Scope of Robotics in Hiatal Hernia Repair
Vinod Kumar Singhal *1, Vidher V V Singhal 2, Umm Heba Asif 3, Faris Dawood Alaswad 4, Varsha Ojha 5
1. General Surgeon, Prime Hospital, Dubai.
2. University College London, London.
3. Bart NHS Trust, London, UK.
4. General Surgeon, NMC Specialty Hospital, Dubai
5. Gynecologist and Obstetrician, Prime Hospital.
Corresponding Author: Vinod Kumar Singhal, General Surgeon, Prime Hospital, Dubai.
Copy Right: © 2023 Vinod Kumar Singhal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Date: March 14, 2023
Published Date: April 01, 2023
Abstract
Background: International guidelines advise laparoscopy as the recommended method for elective surgical hiatal hernia (HH) repair. Robot-assisted laparoscopic surgery (RAS) has become more popular in recent years for a range of surgical procedures.
Objectives: To evaluate the scope and perioperative outcomes, quality of life (QoL), and recurrence rate in patients undergoing robot-assisted laparoscopic HH repair.
Methods: It was a retrospective record based hospital study conducted between July 2020 and June 2022 (2 years), all patients who underwent robot-assisted laparoscopic HH repair and had radiographic or endoscopic confirmation of HH were assessed. During the study period, RAS was used to operate on all consecutive patients who received elective surgical HH repair. Individuals undergoing emergency surgery or revision surgery were not included. Individuals with type I HH only had surgery when they were experiencing symptoms. The total sample size was found to be 40. SPSS was used for analysis.
Results: Out of 40 patients, there were 24 males (58%) and 16 females which shows that the study was male preponderance. The majority of the patients had an American Society of Anesthesiologists (ASA) score of 2 (70%). The most common presenting symptom was reflux (58%), followed by dysphagia (55%). As seen most of the HH has length of >5cm (55%) and 38% has length between 3-5cm. Type 1 hernia has nearly same length. And the comparison was significant. Most of the hernia size is complete (44%). Median operation time was 120 (60–180) minutes, and median blood loss was 26 (8–38) mL. Median duration of hospital stay was 3.4 (1–9) days. In 5 (15%) patients, postoperative complications occurred; 2 had a wound infection, I had an infected seroma and 2 had a perforation.
Conclusion: Robotic repair was equivalent in terms of morbidity and quality of life for HH repair, which showed reduced short-term recurrence rates. Further research is required to examine the utility of RAS for HH repair. Future research should ideally standardize its intraoperative procedures.
Keywords: Robotic assisted laparoscopy, hiatal hernia, recurrence, reflux, quality of life.
Introduction
International guidelines advise laparoscopy as the recommended method for elective surgical hiatal hernia (HH) repair. [1] Since there is no agreement on the procedures used during surgery, such as the inclusion of a fundoplication or the reinforcing of the mesh.[1] Due to the significant recurrence rate of between 10% and 26%, it's critical to find the best fusion of these surgical techniques or other novel procedures with reduced recurrence rates. [2] Robot-assisted laparoscopic surgery (RAS) has become more popular in recent years for a range of surgical procedures. Compared to traditional laparoscopy, RAS may enable surgeons to work more precisely during challenging procedures because of the three-dimensional vision and improved tool handling. [3]
Only a small number of research examined RAS for HH repair, with encouraging preliminary findings [4–6] many investigations lacked standardization their perioperative procedures. This study's objective was to assess the recurrence, perioperative outcomes, and quality of life following a scope of robot-assisted laparoscopic HH repairs.
Materials and Methods
It was a retrospective record based hospital study conducted between July 2020 and June 2022 (2 years), all patients who underwent robot-assisted laparoscopic HH repair and had radiographic or endoscopic confirmation of HH were assessed. During the study period, RAS was used to operate on all consecutive patients who received elective surgical HH repair. Individuals undergoing emergency surgery or revision surgery were not included. Individuals with type I HH only had surgery when they were experiencing symptoms. The total sample size was found to be 40.
Retrospective data on baseline traits and presenting symptoms was gathered from the electronic patient records the size HH type (I-IV), and length. Following a review of the radiographic, upper endoscopic, and postoperative results, the stomach (which is located in the thorax) was rated. The Institutional Review Board approved this study, and informed consent was taken.
Surgical Technique [7]
Each patient underwent a Toupet (270 posterior) fundoplication along with a robot-assisted laparoscopic HH repair without mesh reinforcement. Surgery was carried out by using the da Vinci Surgical System by a skilled robotic upper gastrointestinal surgeon (J.P.R. or R.v.H. (Intuitive Surgical, Sunnyvale, CA). Participants were given general anesthesia and positioned supine. The stomach's pressure was released via a nasogastric tube. A 12-mm blunt-tip port was positioned in the midline of the upper abdomen after sterile exposition and open introduction, and a pneumoperitoneum was created. Three robotic ports and one laparoscopic assistance port were placed after a 30 scope.
The first step was to ensure that the surgical region had a sufficient amount of exposure. The omental bursa was opened at the lesser omentum, and the liver was retracted. After then, you had to take the stomach and hernia sac out of the mediastinum. The hernia sac was entirely separated from the mediastinal tissues, although it was not surgically removed. To get adequate esophageal length to bring the stomach back into the belly, the mediastinal esophagus was moved up to the level of the pulmonary vein. None of the patients received an esophageal lengthening operation. The aorta and vagal nerves were recognized and preserved. The gastroesophageal junction's fat pad and short gastric arteries were both still there. The hiatal defect was then fixed without the use of a mesh by posteriorly approximating the left and right crus with three Mersilene-0 sutures. A Toupet fundoplication was also added. A posterior (270) was executed. Three Mersilene-0 sutures were used to affix the fundus to the right crus and the left side of the esophagus. The ports were then removed under close supervision, the fascia was closed, and the hemostasis was examined.
Intraoperative outcomes were operating time (minutes), blood loss (mL) will be observed. The operating time included the docking time. Postoperative outcome values which are observed are operation-related complications, hospital stay (days), reoperation within 30 days, and mortality and complications. Six weeks after being released from the hospital, patients were seen regularly at the outpatient clinic. If no symptoms were present, patients were released from routine follow-up any ailment
For imaging or endoscopy, (reflux, dysphagia, or discomfort) was seen as justification. Only those patients who were fully asymptomatic were further investigations discontinued. A verified HH by endoscopy or radiology was considered a recurrence.
QoL was evaluated >3 months after surgery with two validated questionnaires. The first was the Short Form-36 (SF-36) questionnaire used for general QoL. The second was the Gastrointestinal Quality of Life Index (GIQLI) questionnaire used for gastrointestinal-specific QoL [7,8]
Statistical Analysis
The statistical analysis was performed using SPSS for windows version 22.0 software (Mac, and Linux). The findings were present in number and percentage analyzed by frequency, percent, and Chi?squared test. Chi?squared test was used to find the association among variables. The critical value of P indicating the probability of significant difference was taken as <0.05 for comparison.
Results
As per table 1 out of 40 patients, there were 24 males (58%) and 16 females which shows that the study was male preponderance. The majority of the patients had an American Society of Anesthesiologists (ASA) score of 2 (70%). The most common presenting symptom was reflux (58%), followed by dysphagia (55%). Upper endoscopy was the most commonly used diagnostic modality (93%), followed by computed tomography (CT; 50%).Most patients (90%) had a Hiatal hernia (PEH), and the most prevalent hernia (80%) was a type III hernia. Median age was 58 years.
As per table 2 hernia length was calculated as distance between the z-line and the diaphragmatic impression and Hernia size was proportion of the stomach located in the thorax. As seen most of the HH has length of >5cm (55%) and 38% has length between 3-5cm. Type 1 hernia has nearly same length. And the comparison was significant. Most of the hernia size is complete (44%).
As per table 3 Median operation time was 120 (60–180) minutes, and median blood loss was 26 (8–38) mL. Median duration of hospital stay was 3.4 (1–9) days. In 5 (15%) patients, postoperative complications occurred; 2 had a wound infection, I had an infected seroma and 2 had a perforation. So reoperation was required in 4 patients only in less than 30 days. There was no mortality. Only 1 patient has recurrence after median follow up of 10 months.
As per table 4 the median GIQLI (gastrointestinal specific QoL) score was 110 (range 56–141), and median SF- 38.4 (general QoL) score were 38.1 (range 20.6–57.8) and 39.6 respectively but not significant.
Discussion
In this study, robot-assisted laparoscopic HH repair was shown to have a low clinical recurrence rate. Furthermore, Blood loss, surgery time, morbidity, and QoL scores were all satisfactory peri-operative results. The use of RAS for HH repair may be a factor in the reduced recurrence rate. This made it possible to precisely separate the mediastinum's hernia sac in its entirety. Since all of the standard laparoscopic instruments must pass through the diaphragm opening and are consequently in a parallel position similar to single-incision surgery, the surgeon's hand's range of motion is constrained during this stage of the process. [9] Because of the three-dimensional vision and the improved manipulation, RAS makes it easier for surgeons to do operations. [10] As a result, the esophagus can be completely mobilized up till the level of the pulmonary veins.
Draaisma et al stated was the only one to examine the rate of HH recurrence after RAS, and they found that it was 12.5% one year after surgery. [11] Though it must be emphasized that in their investigation, normal radiological follow-ups were carried out on every patient, and fundoplication was not a common practice. Only symptomatic individuals had radiological imaging done in the current investigation. This strategy was chosen since a prior study, which was primarily influenced by the severity of symptoms, revealed that only 20%–30% of patients with a radiological recurrence required a reoperation. [12]
The intraoperative procedures employed could be another reason for the low recurrence rate [13,14]. Given that there isn't a consensus regarding the best type of fundoplication to use during HH repair, every patient in this study had a Toupet fundoplication procedures. The literature on the usage of a mesh during HH repair is not definitive [15,16] Mesh was not utilized in this investigation. Given that the Toupet fundoplication is connected to the crus, it might support the diaphragm and reduce pressure on the sutured cruroplasty. Hence, the necessity of a mesh is avoided by performing a Toupet fundoplication following a sufficient cruroplasty with sutures.
In terms of blood loss, surgery time, and morbidity rates, the perioperative outcomes in the current study were comparable to those of prior studies on HH repair [5,6]. Regarding However, this investigation found that gastrointestinal-specific QoL (GIQLI) was poorer than the general population but comparable to a study on laparoscopic HH repair. [14,15] Also, when compared to a study on laparoscopic HH repair, the general QoL (SF-36) physical component was lower and the mental component was greater. [16]
Last but not least, a study on RAS for HH repair was comparable to the reflux-specific QoL (GERDHRQOL). This study featured 1 (2.6%) hospitalized case mortality in a patient with an ASA III and type IV hernia. Mortality resulted from a cecal perforation discovered on postoperative day 8, unrelated to the operation to correct the hernia. [16]
Conclusion
Further research is required to examine the utility of RAS for HH repair. Future research should ideally standardize its intraoperative procedures. Additionally, these studies should address surgeon ergonomics and cost-effectiveness in order to contribute to the continuing discussion about the incremental value of RAS. The literature on laparoscopic repair was equivalent in terms of morbidity and quality of life after robot-assisted laparoscopic HH repair, which showed reduced short-term recurrence rates.
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