Adults undergoing robotic hiatal hernia repair: do surgical and patient factors predict 5-year revision? A systematic...

Robotic hiatal hernia repair (RHHR) has emerged as an innovative alternative to conventional laparoscopic techniques, offering potential advantages in visualization, dexterity, and ergonomics. However, predictors of revision surgery following RHHR remain incompletely understood. This systematic review investigates key surgical and patient factors associated with revision within 5 years following RHHR.

We systematically searched PubMed/MEDLINE, Embase, the Cochrane Library, and Web of Science from inception through July 2025 for studies reporting revision or recurrence after RHHR, following PRISMA 2020 guidance. Eligible studies enrolled adults undergoing primary RHHR (≥ 10 patients) and reported revision or recurrence with at least 12 months of follow-up. Two reviewers independently screened records and extracted data, with disagreements resolved by a third reviewer; methodological quality was appraised using the Newcastle-Ottawa Scale. Because of substantial clinical and methodological heterogeneity (variable hernia size criteria, fundoplication and crural closure techniques, outcome definitions, and follow-up duration), a formal quantitative meta-analysis was judged inappropriate; we therefore performed a structured descriptive synthesis with sample size-weighted pooled estimates where data permitted.

Our analysis included 15 studies comprising 14 independent patient cohorts (references 6 and 7 report the same 1834-patient series, of which 486 were robotic) (Table 1). Overall recurrence rates ranged from 5 to 15%, with the majority of recurrences occurring within the first 2 postoperative years. Revision rates specifically ranged from 0 to 5.7% across studies, with a weighted average revision rate of approximately 3.2% at 5-year follow-up. Hernia size emerged as the strongest predictor of recurrence and revision-large or giant hernias (≥ 5 cm or > 50% intrathoracic stomach migration) demonstrated markedly elevated revision rates reaching 30% in certain series (Table 2; Fig. 2). Studies comparing hernia sizes showed that small to medium hernias (< 5 cm) had revision rates of 0-2%, while large hernias (5-10 cm) had rates of 5-12%, and giant hernias (> 10 cm) showed rates of 15-30%. Mesh reinforcement was inconsistently reported across studies, with approximately 60% of studies documenting mesh usage. Among studies that specified mesh utilization, mesh-reinforced repairs showed revision rates of 2-4% compared to 6-8% in non-mesh repairs (Table 3; Fig. 3), though heterogeneity in reporting prevented definitive statistical analysis. Technical variations including crural closure techniques (simple suture vs. pledgeted vs. mesh reinforced) and fundoplication type (Nissen vs. Toupet vs. Dor) were inadequately standardized across studies (Table 4). Patient factors including BMI (> 35 kg/m²), advanced age (> 70 years), and comorbidities (diabetes, chronic steroid use) showed inconsistent associations with revision risk, with only 6 of 14 cohorts performing multivariate analysis to control for confounding variables.

Hernia size consistently emerges as the primary determinant of revision following RHHR, with larger hernias demonstrating substantially higher revision rates regardless of surgical approach. Based on available data, the 5-year revision rate for RHHR ranges from 0 to 5.7%, with an estimated weighted average of 3.2%. Technical considerations including mesh reinforcement and reconstruction methods remain incompletely understood due to significant reporting variations across studies. Patient-specific factors require further investigation through adequately powered prospective studies. Future research demands rigorous prospective designs with standardized documentation of surgical techniques, hernia characteristics, and patient profiles to better identify and stratify revision risk factors after RHHR. The development of consensus guidelines for reporting outcomes in hiatal hernia surgery would facilitate meaningful comparison across studies and improve our understanding of optimal surgical approaches.