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Purpose: Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique., Methods: Seventy patients (23 males and 47 females) with mean age 64 y old (22-92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus., Results: All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180-360). Mean length of stay was 38 h (24-96). Median follow-up was 29 mo (7-51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically., Conclusions: The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches., Competing Interests: Conflicts of Interest: The authors declare no conflict of interest., (© 2020 by JSLS, Journal of the Society of Laparoscopic & Robotic Surgeons.)

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common clinical presentation. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery. Between March 2014 and August 2016, 50 patients (18 males and 32 females) underwent robotic fundoplication (17 sliding and 33 paraesophageal hernias). The mean age of the patients was 58 years. Biosynthetic mesh was used in 28 patients with paraesophageal hernia. The mean operative time was 115 minutes (90-132) in the sliding hiatal hernia group, whereas it was 200 minutes (180-210) in the paraesophageal hiatal hernia group. The mean hospital stay was 36 hours (24-96). Eight patients experienced mild dysphagia which resolved after four weeks. No postoperative dysphagia was recorded at 30-month median follow-up. We experienced one recurrence in the sliding hernia group and two recurrences in the paraesophageal hernia group, with two patients treated robotically. Robotic fundoplication in treating sliding hiatal hernia is feasible and safe but is more challenging in the large paraesophageal group. Improved patient outcomes hinge on the operative technique used and increasing surgeon experience. The increased dexterity that robotic surgery affords enables the esophageal surgeon to more adeptly apply the traditional principles of laparoscopic fundoplication.

Until recently, pneumatic dilatation and intrasphincteric injection of botulinum toxin (Botox) have been used as initial treatments for achalasia, with myotomy reserved for patients with residual dysphagia. It is unknown, however, whether these nonsurgical treatments affect the performance of a subsequent myotomy. We compared the results of laparoscopic Heller myotomy and Dor fundoplication in 44 patients with achalasia who had been treated with medications (group A, 16 patients), pneumatic dilatation (group B, 18 patients), or botulinum toxin (group C, 10 patients). The last group was further subdivided according to whether there was (C2, 4 patients) or was not (C1, 6 patients) a response to the treatment. Results for groups A, B, C1, and C2, respectively, were: anatomic planes identified at surgery (% of patients)--100%, 89%, 100%, and 25%; esophageal perforation (% of patients)--0%, 5%, 0%, and 50%; hospital stay (hrs)--26+/-8, 38+/-25, 26+/-11, and 72+/-65; and excellent/good results (% of patients)--87%, 95%, 100%, and 50%. These results show that: (1) previous pneumatic dilatation did not affect the results of myotomy; (2) in patients who did not respond to botulinum toxin, the myotomy was technically straightforward and the outcome was excellent; (3) in patients who responded to botulinum toxin, the LES muscle had become fibrotic (perforation occurred more often in this setting, and dysphagia was less predictably improved); and (4) myotomy relieved dysphagia in 91% of patients who had not been treated with botulinum toxin. These data support a strategy of reserving botulinum toxin for patients who are not candidates for pneumatic dilatation or laparoscopic Heller myotomy. [ABSTRACT FROM AUTHOR]

Background: Better understanding of the pathogenesis of gastroesophageal reflux disease in recent years has not been accompanied by appreciable advances in the design of antireflux operations. In many cases, operations are still being performed just as they were described 30 years ago. It is important now to go beyond the eponymous procedures traditionally associated with antireflux operations and to identify the technical elements that contribute to effective and durable fundoplications. Objectives: To compare antireflux operations and identify the important technical elements. Design and Setting: Retrospective study in a university-based tertiary care center. Patients: Two hundred one patients had laparoscopic fundoplications for gastroesophageal reflux disease. The first 22 patients underwent Nissen-Rossetti procedures (360° wrap; no division of short gastric vessels). Subsequently, 82 patients had a total (360° Nissen wrap) fundoplication and 97 patients had a partial (240° Guarner wrap) fundoplication (both with the short gastric vessels divided), with the choice between them based on the quality of esophageal peristalsis. The 3 groups of patients were similar in age, duration of symptoms, incidence of hiatal hernia, and incidence of esophagitis. Main Outcome Measures: Resolution of heartburn, incidence of postoperative dysphagia, and stability of the reconstruction. Results: The resolution of heartburn was achieved for 15 patients (68%) who had the Nissen-Rossetti procedure, 73 patients (89%) who had a 360° Nissen wrap, and 88 patients (91%) who had a 240° Guarner wrap. Postoperative dysphagia occurred in 3 patients (14%) having the Nissen-Rossetti procedure, 5 patients (6%) having a 360° wrap, and 2 patients (2%) having a 240° wrap. Herniation or disruption of the wrap occurred postoperatively in 9 patients (4.5%). Review of the videotapes of these 9 operations showed that important technical elements had been omit... [ABSTRACT FROM AUTHOR]