Application of robotic surgery for paraesophageal hiatal hernia repair: a narrative review

Background and Objective: Paraesophageal hiatal hernia (PEH) repair has undergone evolution from open approaches (e.g., laparotomy, thoracotomy) to minimally-invasive techniques with laparoscopy. While the laparoscopic approach has offered decreased morbidity, issues related to PEH recurrence persist. As a result, there has been a continued need for innovation of PEH repair techniques to address recurrence. Increased uptake in robotic surgery has allowed for application of this technology to PEH repair. While increasing in adoption, the efficacy of robotic approach to PEH continues to undergo evaluation. Methods: We performed a review of randomized and non-randomized studies surrounding robotic-assisted PEH repair using PubMed/MEDLINE. We evaluated the literature across aspects pertaining to perioperative outcomes, long-term outcomes, and costs compared to traditional surgical approaches. There were no publication date restrictions. Key Content and Findings: Current literature suggests that robotic PEH repair is feasible and offers perioperative outcomes similar to standard laparoscopic approaches. Limited reports of long-term outcomes, specifically related to PEH recurrence and patient-reported outcomes, suggest the efficacy of robotic PEH repair. Initial cost comparisons with standard laparoscopic approaches demonstrate similar intraoperative costs, but are limited and continue to be evaluated. In addition, there is data suggesting robotic PEH repair may be applicable to large PEH (>30% intrathoracic stomach). Conclusions: Review of current literature suggests that robotic PEH repair is feasible and has similar perioperative outcomes when compared to standard laparoscopic techniques. The learning curve for transition from laparoscopic to robotic PEH repair needs to be considered, even among experienced laparoscopic surgeons. Future prospective multi-institutional studies will be needed in order to fully evaluate the value (quality/costs) of robotic PEH repair to ensure efficacious and cost-effective adoption.