Da Vinci-assisted vs laparoscopic nissen fundoplication for GERD: a systematic review and meta-analysis of randomized controlled trials on patient-reported outcomes, dysphagia, and long-term failure.

Abstract

The comparative effectiveness of da Vinci robot-assisted versus conventional laparoscopic Nissen fundoplication for gastroesophageal reflux disease remains controversial despite increasing adoption of robotic platforms. Previous meta-analyses have yielded conflicting results regarding patient-centered outcomes and long-term durability. We conducted a systematic review and meta-analysis of randomized controlled trials comparing da Vinci-assisted versus conventional laparoscopic Nissen fundoplication. This review was prospectively registered with PROSPERO (CRD420251139110). We searched MEDLINE, Embase, Cochrane CENTRAL, Web of Science, Scopus, ClinicalTrials.gov, WHO ICTRP, and grey literature sources through August 2025. Primary outcomes included postoperative dysphagia, proton pump inhibitor use, and intraoperative complications. Secondary outcomes encompassed reoperation rates, operative time, length of stay, and conversion to open surgery. Risk ratios and mean differences were calculated using random-effects models. Evidence certainty was assessed using the GRADE methodology. Four randomized controlled trials involving 160 patients (79 robotic, 81 conventional laparoscopic) met the inclusion criteria. No significant differences were observed in early dysphagia (RR 1.05, 95% CI 0.45-2.45), postoperative proton pump inhibitor use (RR 0.97, 95% CI 0.25-3.79), or intraoperative complications (RR 0.43, 95% CI 0.07-2.81). Secondary outcomes showed no differences in reoperation rates (RR 1.65, 95% CI 0.40-6.90), length of hospital stay (MD -0.03 days, 95% CI -0.41 to 0.36), or conversion rates (RR 1.23, 95% CI 0.19-7.99). Operative time demonstrated substantial heterogeneity; sensitivity analysis revealed significantly longer times with robotics when one outlier study was removed (MD 40.28 min, p < 0.00001). Da Vinci robot-assisted and conventional laparoscopic Nissen fundoplication achieve equivalent clinical outcomes with no significant differences in patient-reported outcomes, complications, or long-term effectiveness, while robotic procedures consistently require longer operative times and substantially higher costs without demonstrable clinical benefits. These findings question the routine application of robotic platforms in antireflux surgery until cost-effectiveness and operative efficiency are optimized.