Understanding fundamental differences in symptomatic outcomes of hiatal versus paraoesophageal hernia robotic repairs

Hiatal hernia (HH), or type I paraoesophageal hernias (PEH), can commonly be grouped along with types II-IV PEHs. The fundamental operation performed for repair is similar for all types. We question whether the clinical outcomes following surgical repair differ. The objective of this study is to determine the differences in clinical outcomes when comparing robotic-assisted surgical repair of HH versus types II-IV PEHs. This is a retrospective study analyzing 602 consecutive patients that underwent robotic-assisted repair of a PEH between August 2018 and June 2024. Data were retrieved from an IRB-approved database (IRB21-014). Tertiary referral center. Eligibility criteria included patients with objective findings of a PEH on diagnostic testing. 184 patients were excluded due to: emergent operation, repeat operations, conversion to open operation, patients pending follow-up, and patients lost to follow up. Patient demographics were consistent with a population-based sample. All patients underwent robotic-assisted laparoscopic PEH repair with a fundoplication using the Da Vinci Xi robotic system (Intuitive Surgical, Sunnyvale, CA). No mesh implantation was used. The primary study outcome was post-operative symptomatic improvement when comparing HH repairs versus types II-IV PEH repairs. Secondary outcomes included other perioperative outcomes. The hypothesis was formulated before data collection started. Patients in the HH cohort showed significant reflux symptom improvement postoperatively (98% vs 12.2%, p < 0.01). PEH patients also showed similar improvements in reflux symptoms (84.8% vs 25%, p < 0.01). Symptomatic improvement of dysphagia was found to be significant only in the PEH cohort (54% vs 17.8%, p < 0.01). HHs and PEHs are two distinct entities that present with different symptoms; however, the fundamental operation is similar. Symptomatic outcomes differ between the two patient populations, even with the same surgical management.