A standardized robot-assisted technique for giant paraesophageal hernia repair: the relationship between surgical details and low recurrence rate in long-term follow-up

Purpose: Giant Hiatal Hernia (GHH) is defined as a hiatal hernia that includes at least 30–50% of stomach in the chest. Laparoscopic approach may be challenging with high recurrence rates. Robotic surgery may overcome some laparoscopic limits, but its role is still debated. Methods: We analysed a multicentric prospective database from 2011 to 2023 at General and Robotic Surgery Unit of San Giovanni Battista Hospital (Foligno-Spoleto, Italy) and General Surgery Unit of San Donato Hospital (Arezzo, Italy). A Robotic-Assisted Repair (RAR) was performed in all cases following a standardized surgical technique consisting of 6 steps. A literature review was carried out to identify surgical details linked to better outcomes. Results: 47 consecutive patients underwent RAR. Four procedures were performed in emergency setting and 2 were redo-surgery. 1 (2%) conversion to open was required. Mean operative time was 158 min (range 90–235), and mean length of stay was 2.9 days (range 2–7). Fundoplication was performed in 97% of cases, while cruroplasty using pladgets in the 100%. Bioabsorbable mesh was used in 95% of patients. Anterior gastropexy or gastrostomy was made in the 85%. No patients were readmitted within 30 days, while 3 (6%) showed radiologic recurrences without clinical symptoms at long-term follow-up. Conclusions: A standardized surgical technique in GHH repair achieves lower postoperative complications and recurrence rates even in a long-term follow-up. Robotic platforms allow for safer and technically easier procedures, also in emergency scenarios. Higher costs may be balanced by better postoperative outcomes when compared to conventional literature laparoscopic outcomes.