Voluminous hiatal hernias - the role of robotic surgery

Robotic surgery has become increasingly prevalent in UGI surgery over the last decade, particularly for treating hiatal hernias. Voluminous hiatal hernias, defined as the herniation of 30-50 % of the stomach into the thorax, often require surgical intervention due to associated dysphagia and potential severe complications. Given the challenges of repairing voluminous hiatal hernias, especially in elderly and fragile patients, the surgical technique should be optimal. Robotic surgery affords excellent visualization, allowing high mediastinal dissection and precise hiatus reconstruction. Despite the clear technical advantages, it remains to be demonstrated if the robotic approach matches the outcomes of conventional laparoscopic techniques. We review here the fundamentals of hiatal hernia surgery and describe our surgical technique using the da Vinci Xi robot to operate voluminous hiatal hernias. Additionally, we performed a systematic research analysis and selected recent publications focusing on robotic surgery for voluminous hiatal hernias. Recent studies report comparable complication rates, recurrence, and hospital stay lengths between robotic and laparoscopy surgery. Initial robotic procedures had longer operative times, which decreased with surgeon experience. Most of the studies were observational and retrospective, reporting the experience of a single center. Robotic surgery appears to be a viable option with similar complications rates to laparoscopic surgery under optimized conditions. Current literature supports the broader adoption of robotic surgery for voluminous hiatal hernias. However, prospective randomized studies are needed to further validate its use.