Foregut surgery is a broad term that encompasses a range of disease pathology and procedures. In this chapter, we will discuss the basic construct and robotic technique for four different foregut procedures—paraesophageal hernia repair, Nissen fundoplication, Toupet fundoplication, and Heller myotomy. The field of foregut surgery is a dynamic one, with continual changes in operative technique leading to improved patient outcomes. Surgeries that were once performed open have been successfully performed laparoscopically; those that were once performed laparoscopically are now being performed with robotic assistance.
Hiatal hernias are divided into four types based on their anatomic classification. A type I hernia is also known as a sliding hiatal hernia; the stomach and fundus remain below, and the gastroesophageal junction (GEJ) migrates above the diaphragm. A type II hernia is a pure paraesophageal hernia; in this type, the GEJ retains its normal anatomic position, but a portion of the fundus hernia goes through the diaphragmatic hiatus adjacent to the esophagus. A type III hernia is a combination of types I and II: the GEJ and fundus herniate through the hiatus with the fundus just above the GEJ. A type IV hernia is one in which an abdominal structure other than the stomach, such as the colon, small bowel, or omentum, herniate through the diaphragmatic hiatus within the hernia sac. A paraesophageal hernia includes types II–IV.
Paraesophageal hernias (PEH) were documented as far back as the sixteenth century. Minimally invasive surgery has been demonstrated to be a safe approach for giant PEH with decreased rates of morbidity and mortality as compared to open surgeries and has experienced exponential growth since its introduction. While the introduction of laparoscopic PEH repair has led to improvements, it still falls short—high mediastinal dissection and low-tension hiatal reconstruction can be significant challenges while operating laparoscopically, and recurrence rates can be as high as 57% even in high volume centers. Robotic-assisted surgery has addressed these shortfalls by providing surgeons with increased degrees of freedom, longer instrumentation, enhanced surgeon-controlled visualization, and improved ergonomics. Additionally, literature has demonstrated that many surgeons rely on robotic-assisted surgery for recurrent hiatal hernias. , The advantages of robotic-assisted PEH repair include decreased postoperative pain, decreased recurrence rates, the ability to repair larger defects that traditionally required open surgery, and decreased length of stay.
Many patients with PEH also report symptoms of gastroesophageal reflux disease (GERD). The role of hiatal hernias in GERD has been debated over the years, with many studies demonstrating that hiatal hernias are closely related to reflux symptoms, reflux esophagitis, Barrett esophagitis, and esophageal adenocarcinoma. There are four primary and widely accepted fundoplication operations for the treatment of GERD—Nissen fundoplication, Toupet fundoplication, Belsey fundoplication, and Dor fundoplication.
Achalasia is a debilitating esophageal condition, impacting 6 in 100,000 individuals, and is the second most common functional disorder of the esophagus requiring operative treatment. Achalasia is a motility disorder characterized by the failure of the lower esophageal sphincter relaxation and an absence of esophageal peristalsis. A variety of treatment modalities exist, including medical management, with treatments such as calcium channel blockers, nitroglycerine, botulinum toxin injections, and pneumatic balloon dilations, and surgical, including laparoscopic, robotic, and peroral endoscopic approaches.
This chapter discusses the basic principles and operative techniques of paraesophageal hernia repair, GERD treatment with either Nissen or Toupet fundoplication, and Heller myotomy. Specialty equipment required for these procedures is listed in the box that follows.
Two Cadiere graspers
One vessel sealer
± Suture cutting needle drive
Patient selection and preparation
For those patients with concern for an isolated paraesophageal hernia, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines for workup of an asymptomatic hiatal hernia can include the following studies: plain chest radiographs, contrast studies, computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), esophageal manometry, pH testing, nuclear medicine studies, transesophageal echocardiogram, and endoscopic ultrasound. These tests can be used to confirm or rule out the presence of a paraesophageal hernia. Plain chest radiographs may identify either air fluid levels within the chest or the presence of a soft tissue opacity. Contrast studies can help determine the size and reducibility of the hiatal hernia, while also allowing for localization of the GEJ, and potentially raising concerns for the possible existence of a short esophagus. CT scans allow for clear visualization of any organs potentially herniated into the thoracic cavity while also allowing for 3D reconstruction to aid in preoperative assessment and planning. EGD allows for direct visualization of the esophageal, stomach, and duodenal mucosa to help identify the presence of erosive esophagitis or Barrett esophagus; it can also aid in the diagnosis of the size and type of hernia present. Esophageal manometry and pH testing play more of a role in the workup of GERD and provide valuable information on motility of the esophagus and acid exposure which may alter surgical planning. Nuclear medicine studies, transesophageal echocardiogram, and endoscopic ultrasound are not typically used for the diagnosis of hiatal hernias but may demonstrate these as an incidental finding while the patient is being evaluated for other health conditions.
For those patients who have either failed medical management of their GERD or desire operative intervention for it, a preoperative evaluation and work up must be completed. Preoperative testing must be completed in any patient prior to operative intervention and include upper endoscopy, pH testing, barium swallow evaluation, and manometry; gastric emptying studies should also be obtained in select individuals. Upper endoscopy should be performed preoperatively in all patients to assess for evidence of Barrett esophagus, stricture, and/or esophagitis.
SAGES has published guidelines on indications for surgical intervention on each type of hiatal hernia. For a type I hernia in a patient without GERD, surgery is not necessary. The only indication for surgical repair of a type I hernia would be GERD, and a fundoplication to address the reflux disease is mandatory. SAGES provides a strong recommendation that all symptomatic PEH should be repaired, particularly those with acute obstructive symptoms or which have undergone volvulus. SAGES also rated the evidence to support repair of a completely asymptomatic PEH as weak, stating that consideration for surgery should include the patient’s age and comorbidities.
For patients suspected of having achalasia, a thorough preoperative evaluation is imperative. Typical symptoms include dysphagia with solids and liquids, regurgitation of undigested food, weight loss, chest pain, nocturnal cough, and heartburn. A barium esophagram can be used to confirm the diagnosis and demonstrates a smooth tapering of the lower esophagus leading to the closed lower esophageal sphincter, with the image resembling a “bird’s beak.” Additional testing to confirm diagnosis and judge severity includes esophageal manometry and upper endoscopy. Manometry for a patient with achalasia will demonstrate esophageal aperistalsis and insufficient lower esophageal sphincter relaxation with swallowing. Upper endoscopy is imperative to rule out an alternative diagnosis, such as pseudoachalasia due to a tumor at the GEJ.
Paraesophageal hernia repair
Like many other surgical procedures, PEH repair has undergone multiple evolutions since its inception. In 2000, Hashemi et al. published their early results comparing laparoscopic to open PEH repair and found that, at that time, laparoscopic repair was associated with a 42% recurrence rate. As use of laparoscopy became more widely adopted and further studies were completed, the recurrence rate became equivalent to open repair, and laparoscopic repair was associated with a shorter overall hospital stay and fewer postoperative complications. As the use of robotic-assisted surgery has become more prevalent, its use in PEH repair has become more universally adopted. Multiple studies have demonstrated that use of robotic-assisted surgery for hiatal hernia repair is associated with significantly shorter length of stay and lower rates of complications, while having similar operating times without differences in readmission rate and mortality as compared to laparoscopic repair. , , Recurrent hiatal hernia repair is known to be associated with higher morbidity and mortality as compared to primary repair, as well as being more technically demanding. Use of robotic-assisted surgery for these operations as compared to laparoscopy has been demonstrated to be associated with lower rates of conversion to open procedures and reduced length of hospital stay.
Positioning, trocar placement, and operative steps
Patient should be positioned supine on the operating room table and prepped and draped in the normal sterile fashion ( Fig. 54.1 ). All pressure points should be padded with gel and foam pads. Patient arms should be extended out just shy of 90 degrees. Ensure that the patient is secured to the OR table with a belt and a footboard in place. The entire procedure is performed at a 30-degree reverse Trendelenburg position. The box that follows outlines the key steps of this operation.
Induce pneumoperitoneum and place trocars are indicated in Fig. 54.1 .
Dock the robot and complete targeting.
Visually inspect the hiatus.
Divide the pars flaccida and the pars condensa with identification of the anterior and posterior vagus nerves.
Dissect the hernia sac to ensure adequate mobilization of the distal esophagus.
Perform tension free closure of crura ± mesh.
Pneumoperitoneum can be established using the Veress needle technique. The robotic camera port should be positioned approximately 13 cm inferior from the xiphoid process. Ensuring that at least 12 cm distance is kept between each trocar, the two additional 8 mm trocars are placed in the left upper quadrant and one in the right upper quadrant (RUQ). An additional port can be placed in the epigastrium or RUQ to be used for liver retraction to enhance visualization during the procedure.
At this point, docking of the robot can begin. The camera is inserted through the camera port and used to finalize placement of the robot arms by completing targeting, using the diaphragmatic hiatus as the target point. The remaining arms are then docked to their respective ports. The liver is retracted to ensure adequate visualization of the stomach and hiatus. Once this is complete, the console surgeon can step away from the patient and go to the console, leaving the assistant and the bedside.
The first step is a visual inspection of the hiatus. The operation is then started by dividing the pars flaccida and pars condensa, ensuring preservation of the replaced left hepatic artery (if present). This is accomplished through use of two cardieres and a vessel sealer. It is imperative that both the posterior vagus nerve is identified to avoid injury and postoperative gastroparesis, which can be challenging in large hiatal hernias. From there, the phrenoesophageal membrane is divided and the anterior vagus nerve is identified to avoid injury. The combination of mobilization of the gastrohepatic ligament and phrenoesophageal membrane facilitates dissection of the hernia sac at the level of the crus. The hernia sac can extend significantly into the thoracic cavity depending on the hernia type and can include abdominal contents such as the omentum, stomach, small bowel, or colon. The dissection of the hernia sac should follow the length of the left crus, facilitating reduction of hernia contents into the abdomen from the thoracic cavity. Attention is then turned to the mobilization of the greater curvature of the stomach, which is performed by taking the short gastric vessels. This can aid in the reduction of the greater curvature and posterior wall of the stomach. This maneuver can also reveal a posterior fatty hernia sac behind the stomach that can need further resection to reduce recurrence risk. At this point in the procedure, the distal esophagus should be evaluated for any further adhesions that would limit its ability to be retracted and those adhesions lysed. Once the sac and distal esophagus have been fully mobilized, a Penrose drain can be placed around the distal esophagus, ensuring that the anterior and posterior vagus nerves are identified and protected. Using the Penrose drain to provide traction, extensive mediastinal dissection is performed to ensure 4 to 6 cm of intraabdominal esophageal length without traction on the GE junction. If a capnothorax is encountered and the patient has hemodynamic fluctuation, then reducing the insufflation pressure should enable completion of the procedure. Next, the diaphragmatic crura should undergo a tension free closure. The hiatal closure is calibrated using a 56 to 58 Fr bougie. This can be accomplished with interrupted 0 nonabsorbable Ethibond sutures with pledgets or with a running nonabsorbable barbed suture. If significant tension is present, then a right crus mobilization with splitting the crus from the IVC is performed to ensure tension free closure. We then place a bioabsorbable mesh to reinforce closure particularly in large defects or in defects with attenuated crura based on surgeon judgment. The mesh is fixed with a combination of sutures and bio glue, and care must be taken to ensure that the mesh is not in contact with the esophagus. A Toupet, Nissen, or a Dor wrap is performed based on manometry ( Figs. 54.2–54.4 ).
GERD is an extremely common condition that affects the lower esophageal sphincter, impacting 18% to 27% of the North American population, 8% to 25% of Europeans, 2% to 7% of East Asians, and 23% of South Americans. This condition can be treated either medically, with use of proton pump inhibitors and/or H2-blockers, or surgically. Failure of medical management, side effects from medications, or GERD complications are indications for surgical intervention. Other indications include high volume reflux, erosive esophagitis, benign stricture secondary to GERD, Barrett’s columnar-lined epithelium (without high grade dysplasia or carcinoma) in conjunction with symptoms not improved with medical treatment, atypical or respiratory symptoms with good response to medical treatment, noncompliance with medical therapy, or risk factors that predict a poor response to medical therapy, such as nocturnal reflux on 24-hour esophageal pH testing, structurally deficient lower esophageal sphincter, mixed reflux of gastric or duodenal fluid, and/or mucosal injury at presentation. In adult patients with GERD, SAGES recommends either partial or complete fundoplication approaches. Selecting between a complete wrap (Nissen) and a partial wrap (Toupet or Dor) should be a joint decision between the surgeon and patient. A Nissen fundoplication would be an appropriate choice for a patient who has normal manometry. In other patients who may have an element of esophageal dysmotility and concerns of postoperative dysphagia, a Toupet or Dor fundoplication may be the better choice, and patients should be counseled about their increased likelihood of experiencing a poorer outcome.
Nissen fundoplication is an excellent surgical treatment for GERD and provides patients with an alternative to life-long medical therapy and its associated side effects. It is often recommended for patients with persistent GERD symptoms despite maximum medical therapy. This procedure can be accomplished both laparoscopically and robotically, with multiple studies evaluating the efficacy of the procedure. There are several benefits to using robotic assistance as compared to laparoscopy when completing a Nissen procedure—significantly lower esophageal acid exposure time postoperatively, enhanced patient satisfaction, and improved quality of life—while having no meaningful change in operating time, postoperative dysphagia, conversion to open procedure, need for reoperation, length of stay, and in-hospital costs. Additionally, robotic assistance has been demonstrated to significantly improve intracorporeal suturing performance, shortening the learning curve, and maintaining the safety of novices in the operating room. The box that follows outlines the key steps of this operation.