Robotic versus Laparoscopic and Open Type IV Hiatal Hernia Repair: An STS General Thoracic Surgery Database Analysis

Robotic techniques are increasingly used for complex diaphragmatic hernia repair; however, their safety in type IV hiatal hernias remains uncertain. We evaluated perioperative outcomes across surgical approaches.

We performed a retrospective cohort study using the Society of Thoracic Surgeons General Thoracic Surgery Database, identifying adults undergoing elective type IV hiatal hernia repair between 2018 and 2022. Patients were stratified by operative approach: robotic, laparoscopic, laparotomy, and thoracotomy. The primary outcome was a composite of major postoperative events. Secondary outcomes included postoperative invasive intervention, initial intensive care unit admission, readmission, and mortality. Multivariable logistic regression adjusted for demographics, comorbidities, prior thoracic surgery, and procedural factors, with robotic repair as the reference.

A total of 2,714 patients underwent repair: 1,281 laparoscopic (47.2%), 1,112 robotic (41.0%), 128 laparotomy (4.7%), and 193 thoracotomy (7.1%). Major postoperative events occurred most frequently after thoracotomy (42.5%) and laparotomy (35.9%), compared with laparoscopic (27.5%) and robotic repair (23.3%). In adjusted models, open approaches were associated with higher odds of major postoperative events compared with robotic repair (laparotomy odds ratio 1.77; thoracotomy odds ratio 2.54), whereas laparoscopic repair was not significantly different. Readmission and mortality were similar across approaches.

Minimally invasive approaches, including laparoscopic and robotic techniques, are associated with favorable perioperative outcomes compared with open repair. These findings support the use of minimally invasive surgery for type IV hiatal hernias when clinically appropriate.