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124
D. B. Jones et al.
patient satisfaction. Educational materials include a website with best practices,
sample pathways, patient literature, and other resources such as videos, FAQs, and
an implementation timeline. The materials assist surgeons and their surgical team
with implementation of an ERP.
Top 21 videos are edited videos of the most commonly performed MIS operations
and basic endoscopy. Cases are straightforward with quality video and clear anatomy.
Pearls are step-by-step video clips of 10 operations. The authors show different
variations for each step. The learner should have a fundamental understanding of
the operation.
SAGES Guidelines provide evidence-based recommendations for surgeons and
are developed by the SAGES Guidelines Committee following the Health and
Medicine Division of the National Academies of Sciences, Engineering, and
Medicine standards (formerly the Institute of Medicine) for guideline development
[3]. Each clinical practice guideline has been systematically researched, reviewed,
and revised by the SAGES Guidelines Committee and an appropriate multidisciplinary team. The strength of the provided recommendations is determined based on
the quality of the available literature using the GRADE methodology [4]. SAGES
Guidelines cover a wide range of topics relevant to the practice of SAGES surgeon
members and are updated on a regular basis. Since the developed guidelines provide
an appraisal of the available literature, their inclusion in the Masters Program was
deemed necessary by the group.
The Curriculum Task Force identied the need to select required readings for the
Masters Program based on key articles for the various curriculum procedures.
Summaries of each of these articles follow the American College of Surgeons (ACS)
Selected Readings format.
Facebook™ Groups
While there are many great platforms available to permit online collaboration by
user-generated content, Facebook™ offers a unique, highly developed mobile platform that is ideal for global professional collaboration and daily continuing surgical
education (Fig.11.5). The Facebook groups allow for video assessment, feedback,
and coaching as a tool to improve practice, and their use to enhance professional
surgical education has been validated by Dr. Brian Jacob’s International Hernia
Collaboration closed Facebook group.
Based on the anchoring procedures determined via group consensus (Table11.2),
participants in the Masters Program will submit video clips on designated SAGES
closed Facebook groups, with other participants and/or SAGES members providing
qualitative feedback. Using crowdsourcing, other surgeons would comment and
provide feedback.
Eight, unique vetted membership-only closed Facebook groups were created for
the Masters Program, including a group for bariatrics, hernia, colorectal, biliary,
acute care, exible endoscopy, robotics, and foregut. The SAGES Robotic Surgery
group is independent of the other groups already in existence and will be populated
11 Overview ofSAGES Masters Program
125
Fig. 11.5 Robotic Surgery Facebook group
126
Table 11.2 Anchoring procedures for Robotic Surgery pathway
Robotic Surgery anchoring procedure by pathway Level
Biliary
Multiport cholecystectomy Competency
Cholecystectomy with IOC or for uncomplicated acute cholecystitis Prociency
Cholecystectomy for difcult/severe acute cholecystitis or common bile duct
exploration (CBDE)
Foregut
Nissen fundoplication Competency
Paraesophageal Hernia Repair or Heller Myotomy Prociency
Redo fundoplication Mastery
Hernia
Primary ventral hernia repair Competency
Primary inguinal hernia repair Prociency
Redo hernia or complex hernia (transversus abdominis release) Mastery
Bariatric
Sleeve gastrectomy or lap band Competency
Roux-en-Y gastric bypass Prociency
Revisional bariatric surgery Mastery
Colorectal
Right colectomy Competency
Left colectomy Prociency
Left colectomy with splenic exure release, colectomy for complex
inammatory disease or advanced cancer
D. B. Jones et al.
Mastery
Mastery
only by physicians, mostly surgeons or surgeons in training interested in a wide
range of robotic surgery applications.
The group provides an international platform for surgeons and healthcare providers interested in optimizing outcomes in a surgical specialty to collaborate; share;
discuss; and post photos, videos, and anything related to a chosen specialty. By
embracing social media as a collaborative forum, we can more effectively and transparently obtain immediate global feedback that potentially can improve patient outcomes, as well as the quality of care we provide, all while transforming the way a
society’s members interact.
For the rst two levels of the Masters Program, Competency and Prociency,
participants will be required to post videos of the anchoring procedures and will
receive qualitative feedback from other participants. However, for the mastery level,
participants will submit a video to be evaluated by an expert panel. A standardized
video assessment tool, depending on the specic procedure, will be used. A benchmark will also be utilized to determine when the participant has achieved the mastery level for that procedure.
Once the participant has achieved mastery level, he will participate as a coach by
providing feedback to participants in the rst two levels. Masters Program participants will therefore need to learn the fundamental principles of surgical coaching.
The key activities of coaching include goal setting, active listening, powerful
inquiry, and constructive feedback [5, 6]. Importantly, peer coaching is much different than traditional education, where there is an expert and a learner. Peer coaching
11 Overview ofSAGES Masters Program
127
is a “co-learning” model where the coach is facilitating the development of the
coached by using inquiry (i.e., open-ended questions) in a noncompetitive manner.
Surgical coaching skills are a crucial part of the Masters curriculum. At the 2017
SAGES Annual Meeting, a postgraduate course on coaching skills was developed
and video recorded. The goal is to develop a “coaching culture” within the SAGES
Masters Program, wherein both participants and coaches are committed to lifelong
learning and development.
The need for a more structured approach to the education of practicing surgeons
as accomplished by the SAGES Masters Program is well recognized [7]. Since performance feedback usually stops after training completion and current approaches
to MOC are suboptimal, the need for peer coaching has recently received increased
attention in surgery [5, 6]. SAGES has recognized this need and its Masters Program
embraces social media for surgical education to help provide a free, mobile, and
easy-to-use platform to surgeons globally. Access to the Masters Program groups
enables surgeons at all levels to partake in the Masters Program curriculum and
obtain feedback from peers, mentors, and experts. By creating surgeon-only private
groups dedicated to this project, SAGES can now offer surgeons posting in these
groups the ability to discuss preoperative, intraoperative, and postoperative issues
with other SAGES colleagues and mentors. In addition, the platform permits transparent and responsive dialogue about technique, continuing the theme of deliberate,
lifelong learning.
To accommodate the needs of this program, SAGES University is upgrading its
web-based features. A new learning management system (LMS) will track progression and make access to SAGES University simple. Features of the new IT infrastructure will provide the ability to access a video or lecture on-demand in relation
to content, level of difculty, and author. Once enrolled in the Masters Program, the
LMS will track lectures, educational products, MCE, and other completed requirements. Participants will be able to see where they stand in relation to module completion and SAGES will alert learners to relevant content they may be interested in
pursuing. Until such time that the new LMS is up and running, it is hoped that the
SAGES Manual will help guide learners through the Masters Program Curriculum.
Conclusions
The SAGES Masters Program Robotic Surgery Pathway facilitates deliberate,
focused postgraduate teaching and learning. The Masters Program certies completion of the curriculum but is NOT meant to certify competency, prociency, or mastery of surgeons. The Masters Program embraces the concept of lifelong learning
after fellowship and its curriculum is organized from basic principles to more complex content. The Masters Program is an innovative, voluntary curriculum that supports MOC and deliberate, lifelong learning.
128
D. B. Jones et al.
References
1. Jones DB, Stefanidis D, Korndorffer JR, Dimick JB, Jacob BP, Schultz L, Scott DJ.SAGES
University Masters program: a structured curriculum for deliberate, lifelong learning. Surg
Endosc. 2017;31(8):3061–71.
2. Dreyfus SE. The ve-stage model of adult skill acquisition. Bull Sci Technol Soc.
2004;24:177–81.
3. Graham R, Mancher M, Miller Woman D, Greeneld S, Steinberg E.Institute of Medicine (US)
committee on standards for developing trustworthy clinical practice guidelines. In: Graham R,
Mancher M, Wolman DM, Greeneld S, Steinberg E, editors. Clinical practice guidelines we
can trust. Washington, DC: National Academies Press (US); 2011.
4. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ,
GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and
strength of recommendations. BMJ. 2008;336:924–6.
5. Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA.Surgical
coaching for individual performance improvement. Ann Surg. 2015;261:32–4.
6. Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging
approach to performance improvement. JAMA Surg. 2016;151:282–3.
7. Sachdeva AK.Acquiring skills in new procedures and technology: the challenge and the oppor-
tunity. Arch Surg. 2005;140:387–9.
Robotic Paraesophageal Hernia Repair
12
KaranR.Chhabra andCharuduttN.Paranjape
Hiatal hernias have a signicant correlation with gastroesophageal reux disease
(GERD), and their management is vital in antireux surgery. Paraesophageal hernias, a specic category of hiatal hernias, often necessitate surgical intervention due
to their distinct symptoms and treatment requirements.
Classification andPathophysiology ofHiatal Hernias
In a typical anatomical arrangement, the gastroesophageal junction (GEJ) and the
stomach are positioned below the diaphragmatic hiatus. Hiatal hernias are categorized as follows, with types II, III, and IV classied as “true” paraesophageal hernias. It is estimated that hiatal hernias may be present in approximately 10–15% of
adults, as determined by radiological studies [1].
Type I (Sliding Hiatal Hernia): In this type, the GEJ ascends through the hiatus into
the mediastinum. Constituting 70–90% of all hiatal hernias, they may not have
clinical signicance unless associated with severe GERD or other symptoms.
Type II: Here, the fundus of the stomach moves into the mediastinum, while the
GEJ remains within the abdomen. These are less common.
K. R. Chhabra (*)
Departments of Surgery and Population Health, NYU Grossman School of Medicine,
New York, NY, USA
Division of Bariatric and General Surgery, Bellevue Hospital Center, New York, NY, USA
C. N. Paranjape
Department of Surgery, NYU Grossman School of Medicine, New York, NY, USA
Division of Bariatric and General Surgery, Bellevue Hospital Center, New York, NY, USA
Newton-Wellesley Hospital, Newton, MA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
S. Samreen et al. (eds.), The SAGES Manual of Robotic Surgery,
https://doi.org/10.1007/978-3-031-86927-3_12
129
130
Type III: This type involves herniation of both the GEJ and a portion of the stomach
and is the most prevalent among the “true” paraesophageal hernias.
Type IV: In this category, the stomach, along with another intra-abdominal organ,
such as the colon or spleen, constitutes the hernia contents.
K. R. Chhabra and C. N. Paranjape
Surgical Decision-Making
Not all sliding hiatal hernias necessitate surgical intervention. Surgery is advised for
sliding hiatal hernias only if patients otherwise meet the criteria for foregut surgery
following objective physiological tests and persistent symptoms despite comprehensive medical treatment. For true paraesophageal hernias, it was once believed that surgery was mandatory for all cases (even asymptomatic ones) due to the risk of sudden
and severe complications like gastric volvulus. However, current understanding indicates that the annual risk of such acute complications is relatively low, around 1% [2].
Consequently, SAGES from 2013 guidelines currently recommend surgery only for
paraesophageal hernias with related symptoms or complications [3]. However, more
recent guidelines from the European Association for Endoscopic Surgery (EAES, published in 2023) favor repair for asymptomatic patients who are otherwise reasonable
surgical candidates based on improvements in surgical outcomes in the last decade [4].
Surgical Technique
Laparoscopic and robotic transabdominal approaches are now the predominant methods for treating paraesophageal hernias. Transthoracic approaches represent less than
2% of these procedures and are outside the scope of this text [5]. Of transabdominal
approaches, laparoscopic repairs remain nearly 10 times more common than robotic
repairs in the United States, though this difference is likely to narrow with time [6].
There is currently little high-quality evidence comparing the results of laparoscopic and robotic hiatal hernia repair. The existing literature consists largely of
single-center studies with low sample size and designs that are subject to unmeasured confounding. Generally, robotic approaches have been associated with longer
operative time, shorter length of stay, and mixed results with regard to complications and recurrences [6–9]. The robotic approach does not change our decisionmaking regarding whether to offer paraesophageal hernia repair, but we have found
robotic repair to be preferable to laparoscopic repair in several scenarios: high BMI,
large (including type IV) hernias, or reoperative repairs. In these cases, the visualization and dexterity afforded by the robot are preferable to that achieved laparoscopically. In addition, the length of the robotic arms means that one can use similar
port placement regardless of the size of the hiatal hernia.
Positioning andSetup
The following instructions are applicable to the Da Vinci Xi Surgical System
(Intuitive Surgical, Sunnyvale, CA), the predominant platform used throughout
12 Robotic Paraesophageal Hernia Repair
131
the United States. Compared to its predecessor the Si, the Xi can be docked in a
variety of arrangements depending on the setup of the operating room. A typical
OR setup is depicted in Fig.12.1. We typically dock the robot from the patient’s
left side, with a liver retractor post placed on the patient’s right. The patient is
positioned supine, with arms extended, and a footboard to enable steep (15
degree) reverse Trendelenburg positioning. An orogastric tube is placed for gastric decompression but a Foley catheter is typically not placed. If visualization
is adequate, we limit insufation pressure to 10mm Hg in order to minimize the
subcutaneous emphysema that can develop during an extended mediastinal
dissection.
Our preferred port placement is depicted in Fig.12.2. We begin with a Hasson
technique through or above the umbilicus, but other approaches to peritoneal access
are also reasonable. The four robotic working ports are spaced across the abdomen
at the level of the umbilicus. The ports are aimed toward the patient’s left shoulder
to limit torque and postoperative pain. The bedside assistant sits at patient’s right
with a 12mm Airseal assistant port (optional) placed slightly below the level of the
robotic ports, between arms 1 and 2. A Nathanson liver retractor is placed in the
Fig. 12.1 An operating room setup for robot-assisted laparoscopic paraesophageal hernia repair
using a side docking technique
132
Fig. 12.2 The authors’
preferred port placement.
Robotic ports are spaced
equally across the
abdomen, a minimum of 1
hand-breadth apart, at the
level of the umbilicus
K. R. Chhabra and C. N. Paranjape
right upper quadrant. We recommend using a short arm for the Nathanson liver
retractor to avoid arm collisions. Our preferred instruments are as follows:
Arm 1. Cadiere or another atraumatic grasper.
Arm 2. 8mm 30-degree camera.
Arm 3. Energy device—either Synchroseal or Vessel Sealer Extend. We prefer the
Synchroseal because it has a faster cycle time and a ner dissecting tip, but it has
a longer learning curve than the Vessel Sealer Extend and requires a separate
energy generator.
Arm 4. Cadiere or another atraumatic grasper.
Additional instruments are rarely needed. To omit the assistant port, sutures and
other supplies can be placed into the peritoneal cavity prior to docking the robotic arms.
Operative Technique
Once the arms have been docked, the liver retractor has been placed, and the patient
has been positioned in steep reverse Trendelenburg position, we manually reduce
the hernia contents using atraumatic graspers. We then enter the lesser sac using an
12 Robotic Paraesophageal Hernia Repair
133
energy device through the pars accida on the right. It is critical to enter the plane
between the medial hernia sac and the lateral crura, preserving the fascia over the
crura for easier closure and while staying outside the hernia sac (Fig.12.3). This
dissection is extended anteriorly across to the left crus. At this point, we mobilize
the short gastric vessels as needed in order to facilitate the later fundoplication.
The dissection proceeds posteriorly around the esophagus, using a Penrose drain
or one of the robotic arms for retraction and ensuring total mobilization of the sac
from the chest and mediastinum (Fig.12.4). As the stomach and esophagus are
repositioned into the abdomen, the vagus nerves are identied and preserved. The
dissection continues, freeing esophageal attachments to the mediastinum to achieve
at least 2–3cm of tension-free intra-abdominal esophagus. The hernia sac is generally resected using an energy device.
After ensuring sufcient esophageal length, we close the hiatus. No single suturing method has been deemed superior; however, a posterior repair with permanent
suture is commonly favored. Our preference is to use permanent barbed suture (specically 9” 0 V loc®, Medtronic, Minneapolis, MN). We suture this in a running
horizontal mattress pattern, in order to distribute tension across the crura. Interrupted
sutures are also commonly used. Key considerations include avoiding aortic injury
when suturing near the left crus, and avoiding the inferior vena cava when suturing
the right crus. It is ideal to incorporate some of the fascia overlying the crura to
decrease the risk of sutures pulling through. The wristed robotic instruments facilitate careful yet efcient closure while minimizing tissue trauma (Fig.12.5).
In general, even large defects are usually closable with sutures alone, without
undue tension. If not feasible, relaxing incisions on the right or left hemidiaphragm
can be performed. The use of mesh is controversial, with the best studies showing
mixed results on long-term hiatal hernia recurrence rates with possible harms,
including chest pain and dysphagia [10–12]. Current guidelines from the EAES
include a “weak”recommendation in favor of mesh to reduce recurrence rates [4].
Fig. 12.3 Developing the
plane between the crura
and hernia sac, while
preserving the
diaphragmatic fascia, the
left gastric vessels, and the
integrity of the hernia sac