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32 Adverse Events inRobotic Assisted Hiatal Hernia Repair
495
is advisable to delay intervention for 6–8weeks as these will commonly resolve
without treatment. When intake is impossible or highly painful, early intervention
should be considered. The most common reasons for dysphagia during the inhospital period are an overly tight repair and/or recurrent hiatal hernia. Several diagnostic options are available under those circumstances. If complaints are sufcient
to consider a recurrent hiatal hernia, CT scanning should be considered using both
oral and intravenous contrast. If the suspicion instead is a fundoplication that is too
tight, a barium swallow is the preferred diagnostic tool.
In-hospital hernia recurrence or complete blockage of food and uids should be
treated within days. The area is well accessible in the rst two weeks after surgery,
and reoperative surgery can usually be performed laparoscopically, preferably with
robotic assistance.
32.7 Late Complications
Fundoplications are designed to provide a one-way valve to prevent the reux of
gastric contents at the gastro-esophageal junction. Many side effects of this treatment are directly related to the function of this newly created valve function, one of
which is the prevention of belching. In some patients this can be debilitating due to
air trapping, with aerophagia or ingestion of carbonated drinks that will aggravate
these symptoms. This side effect is usually called gas bloat and is accompanied with
increased atulence.Postoperative treatment consists of efforts to prevent the
entrance of air into the stomach. This is most easily managed by limiting the intake
of carbonated drinks. In the case of true aerophagia, treatment is more involved due
to the variety of etiologies of the problem, ranging from chewing gum to unconscious behavioral traits or psychiatric problems. The most effective method to prevent gas bloating is operatively tailoring the fundoplication to the patient. Numerous
high quality studies have proven the superiority of a partial fundoplication over a
360 Nissen fundoplication [14–17], with equal long term reux control and less gas
bloating. Preoperative manometric testing will greatly aid in the preoperative
decision- making process for each patient regarding whether a partial or full fundoplication is most appropriate.
In the instance of a para-esophageal hernia, the anatomical defect is most likely
the cause of problems, and an anterior fundoplication after hiatal hernia repair can
be sufcient to avoid reux. This fundoplication is closest to the normal anatomy
and will usually result in physiologic reux without bloating due to air trapping.
Many studies have been published on this subject that report excellent long-term
results.
Recurrent reux after fundoplication is often a symptom of recurrent hiatal hernia, and should be considered when a prior successful repair has now failed to
relieve reux symptoms. Studies [9, 16, 18–20] have identied that some form of
radiologic recurrence is identied in 40%, symptomatic recurrence in 20% and
reoperative surgery is necessary in 10% of patients. The use of mesh seems to result
in less recurrence at the short term but has equivalent long-term results.
496
A. C. Mertens and Ivo A. M. J. Broeders
Patients may also complain of symptoms comparable to the preoperative situation, even in the absence of pathologic reux. This often leads to the resumption of
the use of antacid medication. In order to ascertain the correct etiology for the
symptomatology there are several diagnostic tools available to identify the source of
the situation including CT scanning, barium swallow and 24-h esophageal pHmeasurement. CT imaging is most valuable to conrm the development of a recurrent hiatal hernia and it will often have sufcient resolution to conrm a failed
fundoplication. A barium swallow series can be useful for conrming gastro-esophageal reux and can also indicate a signicant hiatal hernia but, like CT scanning,
does not reveal reux over time. A 24-h esophageal pH measurement provides the
best evidence for recurrent reux and is the investigational method of choice should
there be a lack of demonstration of a failed prior repair as demonstrated by imaging
techniques.
If a recurrent hiatal hernia or failed fundoplication is proven, the choice of treatment is up to the surgeon and more importantly, the patient. In some cases, reinstitution of acid suppression therapy will be sufcient, while in more severe cases
another hiatal hernia repair with fundoplication will be required. It is important to
note that patient satisfaction after reoperation decreases from 85–90% to 70% [20–
23]. Reoperative surgery can be very challenging and should only be performed by
surgeons with a high-volume reux and hiatal hernia repair practice. The ability to
perform primary antireux surgery does not mean that one has to be able to treat
recurrence; referral to centers specialized in reoperative surgery is worthy of
consideration.
The effects and complications of the use of mesh in hiatoplasty is a major source
of controversy in the literature [9, 24]. There are many types and shapes of mesh,
which can be categorized as follows; pledgets (small patches), strips, horseshoe or
V shaped, and circular mesh or reverse “C” shaped. Many types of materials have
been used, mostly polypropylene, ePTFE and biologic or absorbable synthetic
materials.
Over time, mesh contracts. In circumferential mesh shapes this can cause dysphagia or even erosion into the esophagus. Because of these risks, circular meshes
should be avoided at all times.
Mesh erosion into the esophagus is the most feared complication after using
mesh. This may result from contraction in circular meshes, but usually results from
friction over the edge of a mesh that is not covered by diaphragmatic muscle. Mesh
should therefore never be used to bridge a gap in the hiatus. The sole role for mesh
is to support and strengthen a hiatal repair. In case of high tension on the repair, left
or right collateral diaphragmatic incisions need to be made instead of bridging a gap
with articial material. A lateral incision can be covered with an asymmetric mesh
with V shape to cover both hiatal repair and diaphragm incision.
Mesh erosion may initially be suspected due to the development of dysphagia.
Usually the area is scarred, and low-grade infection is limited to the direct location
of the mesh.
32 Adverse Events inRobotic Assisted Hiatal Hernia Repair
497
Parts of the mesh can occasionally be removed by endoscopic techniques. Mesh
removal by laparoscopy or laparotomy is very difcult and will always result in an
esophageal defect that needs to be closed. Oftentimes the damage is tremendous and
partial esophageal resection is required. Mesh erosion with limited symptoms
should perhaps be accepted without intervention in a clinically stable patient.
As previously described in the paragraph on intraoperative complications, vagal
nerve injury is a known complication of hiatal hernia surgery and anti-reux
surgery.
The most common symptoms are dyspeptic complaints, delayed gastric emptying with troublesome intake and/or diarrhea. Any of these complaints are often recognized after the repair of huge hernias because of extensive dissection to create
enough esophageal length.
The risk of vagal nerve damage is higher in reoperative hernia repair because it
is more difcult to recognize the branches in the often very scarred tissue. The
majority of symptoms resolve over time. Meanwhile, conservative treatment should
include drugs with prokinetic effects; such as erythromycin, cisapride, metoclopramide or domperidon in combination with professional advice on intake.
Improvement of symptoms can be expected up to two years after surgery.
In case of persistent and very severe symptoms of gastroparesis, laparoscopic
(robot-assisted) pyloromyotomy or pyloroplasty [25, 26] may be considered, but
results are only moderately successful. Serious delayed gastric emptying has to be
proven before consideration of this intervention.
Persistent pain after hiatal hernia repair and fundoplication is relatively rare and
difcult to treat. Most patients complain of shoulder pain immediately after surgery.
This referred pain usually subsides after a few days but may persist sometimes in
combination with pain in any abdominal compartment. If the anatomic repair is
proven to be intact and reux is absent, this pain is very difcult to treat. Revision
of the repair is not advisable and pain medication in combination with paramedical
treatment is the approach of choice.
Two sources of pain are worth mentioning. Dysphagia is often reported as
abdominal pain; further in-depth questioning allows for easy distinction. The most
important characteristic of dysphagia over other abdominal causes of pain is that the
pain always occurs shortly after swallowing.
A second cause of abdominal pain is splenic infarction. The literature is lacking
in evidence on the incidence of splenic infarction after fundoplication but is estimated at 1% [27–29].
The probable cause of these infarctions is ligation of the short gastric vessels
during the creation of a fundoplication. The short gastric vessels are responsible for
part of the arterial blood supply of the superior pole of the spleen. Generally speaking, the splenic artery will soon take over the blood supply and symptoms subside,
however in some cases the ischemia leads to a splenic abscess with possible chronic
pain.
498
A. C. Mertens and Ivo A. M. J. Broeders
32.8 Conclusion
As with all surgical procedures, adverse events can and will occur. The surgeon
should be vigilant to identify these during and after the operation. Those specic to
the hiatal hernia repair are discussed above and will aid the surgeon to identify and
treat these potential problems.
References
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12. Brenkman HJF, Parry K, Van Hillegersberg R, Ruurda JP.Robot-assisted laparoscopic hiatal
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13. Müller-Stich BP, Reiter MA, Mehrabi A, etal. No relevant difference in quality of life and
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14. Broeders JAJL, Mauritz FA, Ahmed Ali U, etal. Systematic review and meta-analysis of lapa-
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32 Adverse Events inRobotic Assisted Hiatal Hernia Repair
16. Roks DJ, Broeders JA, Baigrie RJ.Long-term symptom control of gastro-oesophageal reux
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SLA.0b013e31828604dd.
18. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recur-
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jamcollsurg.2011.05.017.
19. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic Nissen fundoplication with
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https://doi.org/10.1007/s11605-009-0873-z.
22. Gee DW, Andreoli MT, Rattner DW. Measuring the effectiveness of laparoscopic antireux
surgery. Arch Surg. 2008;143:482. https://doi.org/10.1001/archsurg.143.5.482.
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doi.org/10.1007/s004640080144.
24. Tam V, Winger DG, Nason KS.A systematic review and meta-analysis of mesh vs suture cru-
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25. Toro JP, Lytle NW, Patel AD, et al. Efcacy of laparoscopic pyloroplasty for the treat-
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jamcollsurg.2013.12.024.
26. Shada AL, Dunst CM, Pescarus R, etal. Laparoscopic pyloroplasty is a safe and effective rst-
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27. Wilkinson NW, Edwards K, Adams ED.Splenic infarction following laparoscopic nissen fun-
doplication: management strategies. JSLS. 2003;7(4):359–65.
28. Ipek T, Eyuboglu E, Ozben V. Partial splenic infarction as a complication of laparoscopic
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org/10.1089/lap.2009.0409.
29. Martínez DG, Sánchez AW, García AP.Splenic abscess after laparoscopic Nissen fundoplica-
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499
Reoperation After Robotic Diaphragmatic Hernia Repair
JordanA.Bilezikian, RobertG.Johnson,
W.BordenHooks III, andWilliamW.Hope
33.1 Introduction
Laparoscopic fundoplication is the gold standard for surgical treatment of gastroesophageal reux disease (GERD) [1] (Fig. 33.1). However, robotic surgery is
increasing in many institutions due to the benets of the robotic approach compared
with traditional laparoscopy. These benets include better visualization for the
operator, better dexterity of hand motions translated through instruments, and better
ergonomics [2]. Many studies have compared robotic diaphragmatic hernia repair
with laparoscopic diaphragmatic hernia repair and have reported similar in-hospital
Fig. 33.1 Laparoscopic
Nissen (360°)
fundoplication performed
for medically refractory
GERD
33
J. A. Bilezikian (*) · R. G. Johnson · W. BordenHooks III · W. W. Hope
New Hanover Regional Medical Center, Wilmington, NC, USA
e-mail: Jordan.Bilezikian@nhrmc.org; Bobby.Johnson@nhrmc.org;
Borden.Hooks@nhrmc.org; William.Hope@nhrmc.org
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_33
501
502
Fig. 33.2 Robotic Nissen
(360°) fundoplication
showing the esophageal
mobilization and the good
visualization possible with
the robotic surgical
approach
J. A. Bilezikian et al.
outcomes, postoperative quality of life, and functional outcomes [3–8]. Robotic
reoperation after index operation failure is increasing as surgeons report that there
is better visualization and easier dissection of anatomic planes [8]. Prospective studies with long term follow-up data are needed to guide surgical treatment during
these difcult reoperations.
33.2 Rationale forRobotic Diaphragmatic Hernia Repair
Robotic diaphragmatic hernia repair is based on principles similar to laparoscopic
repair and is described elsewhere in this book. Similar to other operations that have
both laparoscopic and robotic approaches, the potential benets of the robotic
approach include better visualization, dexterity, and ergonomics [2] (Fig. 33.2).
Benets specic to diaphragmatic hernia repair include better visualization of relevant anatomy and easier dissection of difcult planes with potentially less risk of
intraoperative complications [8]. Since many minimally invasive surgeons are
increasing their robotic operative volumes, robotic surgery has become their default
approach for selected operations.
33.3 Indications forReoperative Diaphragmatic
Hernia Repair
As with most hernia operations, the most common reason for reoperation is hernia
recurrence (Fig.33.3). However, unlike other types of recurrent hernias requiring
reoperation, diaphragmatic hernia recurrences can be treated with conservative
management in select patients. Conservative treatment can be justied in patients
with mild to moderate symptoms. Severe dysphagia or recurrent reux usually
requires a reoperation. In a retrospective cohort study of 103 patients undergoing an
antireux operation at a single institution during a two-year period, the reasons for
reoperation were dependent on the type of fundic wrap chosen in the index operation [9]. In patients undergoing a Nissen fundoplication, the most common reason
was dysphagia, and in patients undergoing a Toupet, it was recurrent reux [9].
33 Reoperation After Robotic Diaphragmatic Hernia Repair
Fig. 33.3 Recurrent
hiatal/paraesophageal
hernia following robotic
repair. The stomach is seen
going through hiatal defect
and into chest
503
33.4 Mechanism ofFailures ofRobotic Diaphragmatic
Hernia Repair
Although no studies have analyzed robotic antireux surgery failures, a consecutive series by Stein etal. of 105 patients delineated the causes of laparoscopic
antireux surgery failures [10]. In this study, technical factors and inappropriate
patient selection were the most common reasons for failures of antireux laparoscopic surgery [10]. More specically, the reasons for failure were disruption of
the initial antireux procedure (46%), a displaced repair (23%), too-tight or toolong fundoplication (10%), an unrecognized motor disorder (9%), paraesophageal
or axial herniation (6%), or gastric denervation (6%) [10]. Seventy-one of 105
patients required surgical revision, and the remaining 34 patients were treated
with a conservative approach [10]. An intraoperative assessment of patients who
required reoperation showed technical errors responsible for failure of the initial
operation in 40 of 71 patients [10].
Other studies describe the failures and reoperation rates of laparoscopic antireux surgery. Awais et al. retrospectively reviewed 275 patients undergoing redo
surgery by thoracic surgeons for failed fundoplication and demonstrated that transmediastinal migration-recurrent hernia was the most common pattern of failure in
64% of patients [11]. Of note, the thoracic surgeons completing these complex redo
esophageal antireux operations had signicant laparoscopic and open esophageal
surgical experience [11].
Robotic antireux surgery has mechanisms of failure similar to those listed
above, which include disruption or displacement of original repair and improper
fundoplication. Surgeons should analyze trends in their patients’ technical failures
that require reoperation and consider modications to prevent future failures.
504
J. A. Bilezikian et al.
33.5 Treatment Options forRecurrent Diaphragmatic Hernia
Following Robotic Repair: Overview ofStrategies
As discussed, recurrent diaphragmatic hernias can be treated with reoperation or
conservative therapy depending on symptom severity and other patient-specic factors. Reoperative repair presents unique challenges due to varying degrees of adhesions, inammatory changes, and anatomic distortion (Fig.33.4).
Reoperative diaphragmatic hernia repair applies principles similar to those
described elsewhere in this book. The surgeon should obtain and review the previous operative notes. One should be aware of the original surgical approach, type of
repair, aberrant anatomy, and intraoperative complications that occurred.
The surgeon’s previous experience with reoperative approaches plays an important role in surgical planning and preoperative decision making. After consideration
of all patient-specic factors and a surgical approach is chosen, three criteria are
essential for a successful reoperation. These are: a complete takedown of the previous repair with identication of the normal anatomy, recognition of a short esophagus, and proper placement of the new fundoplication [11].
33.6 Open Repair
Open diaphragmatic hernia repair is increasingly rare as a primary fundoplication
operation. However, it is still the most common approach for reoperations for recurrent diaphragmatic hernias. Although many general surgeons trained using open
approaches, there is currently more use of the laparoscopic and robotic technique.
Thoracic surgeons may have more experience with open diaphragmatic hernia
repairs depending on their established practice. In some cases, thoracic approaches
may be preferred in reoperative settings. When surgeons are not comfortable using
these approaches, consultation with a thoracic surgeon may be warranted.
Fig. 33.4 Reoperative
hiatal hernia repair with
severe adhesions of
stomach to liver requiring
meticulous sharp
dissection
33 Reoperation After Robotic Diaphragmatic Hernia Repair
Fig. 33.5 Dissection of
right crus. Previously done
wrap has slipped/migrated
above the crus and must be
reduced. Tissue planes can
often be difcult in
reoperative foregut surgery,
and careful delineation of
the anatomy is crucial for a
successful outcome
505
The patient’s risk factors for undergoing an open repair must be considered, as
should the risk/benets of undergoing an invasive operation with increased risk of
morbidity and increased hospital length of stay. Open repair is a fairly common
reoperative approach, unless the surgeon is more experienced with reoperations
using a laparoscopic/minimally invasive modality.
33.7 Laparoscopic Repair
Laparoscopic repair appears to be declining in usage for recurrent diaphragmatic
hernias due to the advent of robotic technology in many institutions. Reoperative
laparoscopic fundoplications have a signicantly higher morbidity than primary
laparoscopic fundoplications [12]. This is due to the complex nature of this procedure, the difculty to clearly delineate tissue planes, and distorted anatomy due to
the initial operation and resultant adhesions (Fig.33.5). However, the surgeon may
decide that the original repair failure is more easily repaired using a laparoscopic
approach. The laparoscopic approach may be selected when a surgeon is well
trained in this approach for reoperations and does not anticipate benets in overall
morbidity by using an open approach.
33.8 Robotic Repair
Robotic repair for recurrent diaphragmatic hernia is a reasonable surgical approach.
Although some studies have demonstrated higher costs and longer operative times
for robotic surgery, in general [13–15], there are potential benets with robotic surgery for reoperations in these complex cases [13]. As previously stated, reoperative
laparoscopic diaphragmatic hernia repair has higher morbidity than primary laparoscopic repair. It is assumed that robotic surgery is similar. Interestingly, in a recent