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Robotic Giant Paraesophageal Hernia Repair
CaitlinHoughton
Introduction
Foregut surgery is a relatively new indication for robotic surgery. Although surgeons have been utilizing the platform for
these surgeries, FDA approval of the Xi da Vinci system just
came in early 2021. Robotic foregut surgery is on an exponential rise largely due to the superior HD visualization; the
ease in working in tight spaces, such as through the hiatus;
and the precision of tissue dissection. The advancement in
energy devices and instrumentation has also allowed the
platform to be used in increasingly complex procedures such
as cases of intra-thoracic stomach or giant paraesophageal
hernias.
9
Procedure: Illustrated Steps
Figures 9.1, 9.2,9.3, 9.4, 9.5, 9.6, 9.7, 9.8, 9.9, 9.10, 9.11,
9.12, 9.13, 9.14, 9.15, 9.16, 9.17, 9.18, 9.19, 9.20, 9.21, 9.22,
9.23, 9.24, 9.25, 9.26, 9.27, 9.28, 9.29, 9.30, 9.31, and 9.32
show the procedure.
C. Houghton (*)
Department of Surgery, Keck School of Medicine, University of
Southern California, Los Angeles, CA, USA
e-mail: caitlin.houghton@med.usc.edu
Fig. 9.1 Trocar placement includes four robotic trocars and a
Nathanson retractor. The camera port is in the left paramedian space.
Two trocars in the left upper quadrant: one in the midclavicular line and
one in the anterior axillary line. One trocar in the RUQ placed to avoid
the liver edge
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
O. Y. Kudsi, P. P. Grimminger (eds.), Atlas of Robotic Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-86578-8_9
81
82
C. Houghton
Fig. 9.2 Giant paraesophageal hernia noted on initial inspection
Fig. 9.3 Identify and expose the pars accida of the gastrohepatic
ligament
Fig. 9.4 Divide the pars accida and march up to the right crus
Fig. 9.5 Splay out the peritoneal covering of the right crus by retract-
ing the adjacent fat
9 Robotic Giant Paraesophageal Hernia Repair
83
Fig. 9.6 Open the peritoneal covering using the vessel sealer extend
down to muscle bers
Fig. 9.7 Open along the entire length of the right crus
Fig. 9.8 Retract the hernia sac to see the muscle bers which will be
gently spread off the sac
Fig. 9.9 Bluntly spreading the muscle bers off the hernia sac lead to
the areolar planes in the mediastinum
84
C. Houghton
Fig. 9.10 Follow the areolar plane to mobilize the hernia sac away
from the anterior mediastinum
Fig. 9.11 Score the peritoneum down to muscle bers along the left
crus to separate the hernia sac from the crural muscle
Fig. 9.12 Using blunt dissection and the areolar tissue planes as a
guide continue to reduce the hernia sac from the mediastinal attachments. Once the hernia sac is reduced, the esophagus will come into
view
Fig. 9.13 Continue mobilizing the esophagus, identifying and preserving the anterior vagus nerve
9 Robotic Giant Paraesophageal Hernia Repair
85
Fig. 9.14 Create the posterior window in the mediastinum by lifting
the esophagus up and gently spreading the connective tissue until a window is made
Fig. 9.15 Place a grasper through the window
Fig. 9.16 Hand yourself a penrose to pull through the posterior
window
Fig. 9.17 Secure the penrose around the distal esophagus to aid in
retraction for the rest of the case
86
C. Houghton
Fig. 9.18 Divide lateral attachments to continue esophageal
mobilization
Fig. 9.19 Continue posterior dissection by dissection in the plane
between the posterior esophagus and the aortic fat
Fig. 9.20 March up along the aorta ligating tributary vessels along the
way
Fig. 9.21 Posterior dissection continues high into the mediastinum to
relieve tension and tp gain intra-abdominal length on the esophagus
9 Robotic Giant Paraesophageal Hernia Repair
87
Fig. 9.22 Completed posterior esophageal dissection
Fig. 9.23 Completed anterior esophageal dissection
Fig. 9.24 Crural closure starts at the conuence of the crura. Protect
the aorta with a grasper while taking a robust bite of the left crus. Nonabsorbable barbed suture
Fig. 9.25 Take a robust bite of the right crus catching the anterior peritoneal covering
88
C. Houghton
Fig. 9.26 Continue running the barbed suture to bring the crural muscles together posteriorly
Fig. 9.27 Close the hiatus until it circumferentially approximates the
esophagus without impinging on it
Fig. 9.28 Hernia is now repaired with 3cm of intra-abdominal esophageal length
Fig. 9.29 Phasix ST mesh is cut and placed posteriorly to reinforce the
hiatal closure
9 Robotic Giant Paraesophageal Hernia Repair
89
Fig. 9.30 Once the hernia is repaired, LES augmentation required.
Anterior partial fundoplication (modied Watson fundoplication) is
used in this case
Fig. 9.31 Fundoplication completed
Fig. 9.32 Endoscopic evaluation of the valve shows a Hill grade 1
valve
References
1. Geoffrey P Kohn MBBS(Hons) MSurg FRACS, Raymond R Price
MD FACS, Steven R Demeester MD FACS, Joerg Zehetner MD,
Oliver J Muensterer MD, Ziad T Awad MD FACS, Sumeet K Mittal
MD FACS, William S Richardson MD FACS, Dimitrios Stefanidis
MD PhD FACS, Robert D Fanelli MD FACS and the SAGES
Guidelines Committee. Guidelines for the management of hiatal
hernia. 2013.
2. Kohn GP, Price RR, Demeester SR, etal. Guidelines for the manage-
ment of hiatal hernia. Surg Endosc. 2013;27(12):4409–28. https://
doi.org/10.1007/s00464- 013- 3173- 3 [published Online First: Epub
Date].
3. Hill LD, Kozarek RA, Kraemer SJM, etal. The gastroesophageal
ap valve: invitro and in vivo observations. Gastrointest Endosc.
1996;44(5):541–7.
Robotic Truncal Vagotomy
andAntrectomy
FazaldinMoghul andAbubakerA.Ali
10
Introduction
Peptic ulcer disease can cause complications requiring surgical intervention; acute complications include perforation and
bleeding, while chronic complications include refractory
ulcers, gastric outlet obstruction, and malignancy. The
Johnson classication of peptic ulcers based on location can
help tailor therapy. Type I ulcers occur on the body of the
stomach along the lesser curve and are associated with normal acid secretion. Type II gastric ulcers occur in association
with an active or previous duodenal ulcer. Type III ulcers are
located in the prepyloric region. Type IV ulcers occur in the
proximal stomach. Type V ulcers can occur anywhere in the
stomach and are associated with chronic NSAID use. Type II
and III ulcers are associated with hyperacid states and benet
from vagotomy and antrectomy or vagotomy and pyloroplasty. Performing antrectomy removes the portion of the
stomach which contain the G cells that are responsible for
secreting gastrin. Vagotomy removes the direct cholinergic
stimulation for gastric acid secretion by the parietal cells and
decreases the parietal cell response to histamine and gastrin
[1]. Truncal vagotomy completely denervates the stomach,
reduces acid secretion, and alters gastric motility. A gastric
emptying procedure should be performed after truncal
vagotomy.
The procedure can be performed open, laparoscopic, or
robotic assisted. Robotic gastric surgery is associated with
less blood loss and length of stay, though there are longer
operative times [2]. The advantage of the robotic approach is
the ability to perform meticulous dissection around a scarred
stomach and duodenum with improved magnication and
articulating movement of instruments.
A robotic antrectomy begins with dissection along the
greater curve from the pylorus cephalad. The lesser curve is
mobilized and the right gastric artery is ligated. The duodenal bulb is dissected off of the pancreas, which may have
signicant scarring. The proximal transection should extend
from the incisura along the lesser curve to the terminal
branch of the right gastroepiploic artery on the greater
curve. The distal transection should be on to the duodenum
to avoid retained antrum syndrome. An anastomosis to
restore gastrointestinal continuity can be performed with a
gastroduodenal or gastrojejunal anastomosis. The patient
shown in this chapter underwent a gastrojejunal, or Billroth
II, reconstruction. Truncal vagotomy involves resecting a
1–2cm portion of the anterior and posterior vagal trunks as
the nerves pass through the esophageal hiatus in the diaphragm. The nerve segments are sent to pathology to conrm the segment is nerve tissue [3].
Procedure: Illustrated Steps
Figures 10.1, 10.2, 10.3, 10.4, 10.5, 10.6, 10.7, 10.8, 10.9,
10.10, 10.11, 10.12, 10.13, 10.14, 10.15, 10.16, 10.17, 10.18,
10.19, 10.20, 10.21, 10.22, 10.23, 10.24, 10.25, 10.26, 10.27,
10.28, 10.29, 10.30, 10.31, 10.32, 10.33, 10.34, 10.35, 10.36,
10.37, and 10.38 illustrate the technical aspects of robotic
vagotomy and antrectomy. The enteric reconstruction is performed with a stapled retrocolic retrogastric Billroth II
gastrojejunostomy.
F. Moghul · A. A. Ali (*)
Department of General Surgery, Wayne State University,
Detroit, MI, USA
e-mail: aaali@med.wayne.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022
O. Y. Kudsi, P. P. Grimminger (eds.), Atlas of Robotic Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-86578-8_10
91