Case report: A novel technique of robotic low-tension hiatal hernia repair using mediastinoplication

Abstract

Surgery for giant hiatal hernias presents significant challenges, with laparoscopic surgery widely regarded as the gold standard. This approach typically involves complete resection of the hernia sac, thorough esophageal mobilization, tension-free closure of the diaphragmatic crura, and proper fundoplication. Despite various strategies to reduce recurrence, such as mesh reinforcement, there is no consensus on their superiority over traditional methods. Robotic surgery introduces greater precision, particularly in complex cases involving large hernias (grades III and IV). It facilitates safer dissections and more effective esophageal mobilization, challenging the concept of a short esophagus. A novel technique, mediastinoplication, addresses the positive abdominal-thoracic pressure gradient, a key factor in hernia recurrence. By reducing mediastinal dead space and approximating mediastinal structures, this technique aims to minimize tension on the crura and reduce recurrence, seroma, hematoma, and abscess. While further validation of mediastinoplication's long-term efficacy is needed, it adheres to fundamental surgical principles and offers a promising solution to high recurrence rates. Future studies are essential to establish its role in standard practice.•Introduces robotic mediastinoplication as a novel technique.•Robotic suturing increases the feasibility of suturing mediastinal structures that are inaccessible by traditional laparoscopic methods.•Mediastinoplication reduces tension, allowing a low-tension hiatal repair.

Keywords: Abdominal-thoracic pressure gradient; Diaphragmatic crura; Giant hiatal hernia; Innovative surgical technique; Low-tension repair; Mediastinal dissection; Mediastinoplication; Minimally invasive procedures; Recurrent hiatal hernia; Robotic Low-Tension Hiatal Hernia Repair Using Mediastinoplication; Robotic surgery.

Graphical abstract

Fig. 1

CT scan (right) showing sagittal and coronal aspect of large hiatal hernia with significant intrathoracic stomach and esophageal displacement.

Fig. 2

A big hiatal defect, with migration of almost all the stomach to the mediastinum.

Fig. 3

Dissection of the mediastinum, releasing the hernial sac from surrounding structures to reduce the gastric herniation.

Fig. 4

Dissection of the esophagus from the mediastinal attachments above the hernial sac.

Fig. 5

Esophagus fully mobilized from mediastinum, with good abdominal length.

Fig. 6

Plication of mediastinal pleura with barbed suture on both sides of the esophagus.

Fig. 7

LEFT: Hiatus diameter before mediastinoplication. RIGHT: hiatus diameter after mediastinoplication. The hiatus diameter is much smaller after the plication.

Fig. 8

Hiatoplasty with interrupted non absorbable sutures. Notice the stitches on the left side of the esophagus.

Fig. 9

Nissen fundoplication.