Robotic Approach to Right-Sided Hiatal Hernia Involving the Ascending and Transverse Colon, Duodenum, and Distal...

Cases of hiatal hernia (HH) involving the distal stomach, duodenum, and ascending and transverse colon are exceptionally rare and present significant surgical challenges owing to severe anatomical distortion. Although minimally invasive surgery is the gold standard for HH repair, the application of a robotic approach to this specific complex configuration involving distal gastric and duodenal herniations has not been previously reported. Here, we present the case of such a defect that was managed successfully using a robotic platform.

A 36-year-old female presented with worsening vomiting and an inability to tolerate oral intake for 1 week prior to admission. Her history included 2 recent pregnancies and deliveries within the last 2 years, which likely precipitated the symptoms due to increased intra-abdominal pressure. CT of the abdomen and pelvis revealed a massive HH. The herniated contents included the lower gastric body, antrum, duodenal bulb, and ascending and transverse colon, all of which were displaced into the right hemithorax via a defect in the right crus of the diaphragm. The patient underwent a total robotic repair using the da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). The procedure involved careful reduction of the herniated viscera and meticulous mediastinal dissection of the hernial sac using a soft coagulation technique. The robotic platform facilitated the identification and preservation of the anterior and posterior vagal trunks. The crural defect was repaired using nonabsorbable sutures (Ethibond 2-0; Ethicon, Raritan, NJ, USA). Owing to the emergency setting and extensive anatomical distortion, anterior gastropexy was performed instead of fundoplication to secure the stomach and prevent recurrence. Obstructive symptoms resolved immediately postoperatively. She successfully transitioned to oral intake. The chest tube was removed on POD 5, and she was discharged on day 7 without complications.

This case demonstrates the feasibility and safety of a completely robotic approach for repairing complex HH involving the distal stomach, duodenum, and ascending and transverse colon. The robotic platform's superior 3D visualization and wrist articulation are distinct advantages for performing precise dissection in the confined mediastinal space, ensuring safe reduction and preservation of critical structures such as the vagal nerves.