Belsey Mark IV Repair for Recurrent Hiatal Hernia and Failed Fundoplication: An Analysis of Outcomes in 206 Patients

Background: With the increasing number of laparoscopic fundoplications, many more patients with a failed primary antireflux operation are being referred for complex redo procedures. The objective of this study was to evaluate our results of redo antireflux surgery using the Belsey Mark IV (BMIV) Repair. Methods: A retrospective analysis of the patients who underwent BMIV repair following a failed fundoplication was performed. The primary endpoint was failure of the redo procedure and recurrent hiatal hernia. Secondary endpoints were assessment of the functional results of the redo fundoplication and quality of life with a Dysphagia Score, and Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQOL) questionnaire. Results: 206 patients underwent surgery for failed primary fundoplication. Most patients had one prior antireflux surgery 148/206 (71.8%). The most common primary failed fundoplication was the Nissen procedure (189/206, 91.7%). The median time from the prior operation to the redo operation was 34 months. Median follow-up was 25.6 months. The Dysphagia score decreased from 3.6 ± 0.5 preoperatively to 1.0 ± 0.4 postoperatively (p < 0.0001). At the time of follow-up, the Median GERD-HRQL score was 4 (range 0 - 9), classified as excellent, compared to a preoperative Median GERD-HRQL score of 43 (range 41 - 50) which was classified as poor. (p < 0.0001). There was no recurrence of the hiatal hernia. Conclusion: Complete takedown and reestablishment of the normal anatomy, recognition of a short esophagus, and proper placement of the wrap are essential components of a redo antireflux procedure. The BMIV repair as the choice of reopertaive procedure results in excellent symptom relief, significant improvement in quality of life, and is associated with excellent medium-term durability in terms of recurrence of the hiatal hernia.

Cardiovascular Complications of Large Hiatal Hernias: Expanding the Indications for Robotic Surgical Anatomic and Physiologic Repair: A Review

Background: Historically, the pathophysiology of Hiatal Hernias (HH) has not been fully understood. As a result, the surgical therapy of HH has focused primarily on gastrointestinal symptoms and Gastroesophageal Reflux (GERD). This treatment strategy has been associated with poor relief of symptoms and poor long-term outcomes. In fact, until recently, most patients with HH have been watched and referred for surgery as a last resort. Recent experience has shown that a large (giant) Hiatal Hernia (GHH) is a common problem known to impact adjacent organs such as the hearts and lungs. Those referred for surgical repair often complain of dyspnea, which is erroneously attributed to pulmonary compression or aspiration, but has been shown to be from tamponade caused from compression of the heart by herniated abdominal contents. This article reviews the present understanding of GHH, the cardiac complications which result from GHH, and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH. Methods: In a prospective cohort study, we evaluated patients undergoing RRHH with at least a 2-year follow-up. All patients undergoing elective (RRHH) were identified preoperatively and enrolled prospectively in this study. Preoperative characteristics, medical comorbidities, and clinical information were all recorded prospectively and recorded into a secure surgical outcomes database. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and at postoperative time points of 1 month, 1 year, and 2 years. Patients routinely had a barium swallow postoperatively before discharge but did not undergo a barium swallow, an endoscopy, or a CT scan study at the 1-month time point unless indicated by symptoms. At 6 months, 1 year, and yearly intervals thereafter, all patients received an endoscopy study to ascertain the presence of a recurrence, regardless of symptoms. Recurrence was defined as over 2 cm or 10% of the stomach above the diaphragm detected by CT, esophagogram or endoscopy. In addition, an extensive search was conducted using Pub Med in order to extract references to the cardiovascular complications of HH. Results: 423 patients underwent RRHH. With a long-term follow-up, there was a significant decrease in the Median Symptom Severity Score from 42.0 preoperatively, to 3.0 postoperatively. Recurrence was seen in 5 patients (5/423) for a recurrence rate of 1.1%. Conclusion: This experience has been the basis of two important realizations: 1) all patients with GHH have at least some degrees of clinically relevant compression of the inferior vena cava and the left atrium which causes tamponade and cardiogenic dyspnea which completely resolves after successful surgical repair;and 2) primary care providers and gastroenterologists who usually treat patients for GHH repair rarely recognize cardiac compression and tamponade as the cause of the shortness of breath and gradual increase in dyspnea on exertion and progressive fatigability in these patients. This article reviews the present understanding of GHH, the cardiac complications which result from GHH and the most advanced robotic minimally invasive surgical approach to the anatomic and physiologic repair of GHH.

Robotic Transthoracic First Rib Resection for Neurogenic Thoracic Outlet Syndrome

Purpose: Neurogenic Thoracic Outlet Syndrome accounts for over 95% of patients with TOS. We report a single institution experience with robotic first rib resection in patients with Neurogenic TOS. Methods: The diagnosis of NTOS was made in patients in whom all specific localizing and diagnostic orthopedic and neurologic conditions were ruled out. Preoperative diagnostic tests included a comprehensive history and physical exam, Chest X-ray, Chest CT, MRI if the cervical spine, Nerve conduction studies, and Magnetic Resonance angiography of the Thoracic outlet with arm maneuvers (MRA). Patients with NTOS who underwent robotic first rib resection with disarticulation of the costosternal joint and scalenectomy. Results: There were 137 patients (47 men and 90 women). Mean age was 34 ± 9.5 years. Operative time was 93 minutes ± 10.3 minutes. There were no intraoperative complications. There was no injury to the subclavian vessels during the dissection. There were no neurovascular complications. There was no 30 or 90 day mortality. Quick DASH Scores (Mean ± SEM) decreased from 60.3+/2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period, and 3.5+/1.1 at 6 months. (P < 0.01) Immediate relief of symptoms was seen in all patients (100%). Complete relief of symptoms was seen in 133/137 (97%) of patients. Conclusions: Robotic resection of the medial aspect of the first rib with disarticulation of the costo-sternal joint is associated with excellent relief of neurologic symptoms in patients with Neurogenic Thoracic Outlet Syndrome.

Diaphragmatic Flap: Technique of Preparation and Indications for Use

Background: The use of a vascularized pedicle flap of diaphragmatic muscle (DF) for reconstructive procedures in the chest has many advantages. Yet, despite the excellent reported results, the use of DF has not been widespread. Some factors for the less widespread use of DF have been, concern about diaphragmatic function, hesitation to use such a vital muscle for reconstructive purposes, and most importantly, the technical aspects for the preparation of the flap. Methods: Using a cadaveric model, the vascular anatomy of the diaphragm and the steps for the preparation of the DF was defined and illustrated for both the right and left hemidiaphragm. Results: No perioperative mortality with the use of DF has been recorded. Function of the native diaphragm has not been impaired. Bronchopleural fistulas and pericardial defects have healed in all instances. Excellent repair has been achieved in all patients with esophageal lesions. The disruption of the repaired native diaphragm and visceral herniation has been reported but it has been attributed to the learning curve and the technique of repair. Conclusion: With a better understanding of the vascular anatomy of the diaphragm and a formal methodical approach to harvesting the DF, more surgeons will be encouraged to use DF with excellent results.

Robotic Laparoscopic Transdiaphragmatic Repair of Large Hiatal Hernias

Introduction: Although laparoscopic Nissen fundoplication is the most common procedure for the repair for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty has been reported as a common mechanism of failure after primary repair. Left transthoracic anatomic and physiologic repair (AFR) of HH is associated with lower incidence of leak and reoperation but greater morbidity. Adopting the transthoracic approach to a robotic laparoscopic platform may represent the ideal approach to the repair of HH. This study reviews the results of this technique. Methods: A retrospective review was performed on patients who had robotic AFR (RAFR) of large HH. All patients received the previously validated Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire preoperatively and postoperatively. Objectively, symptoms were graded using the Visick Scale. Recurrence was defined as greater than 2 cm or 10% of the stomach above the diaphragm detected by either CT, esophagogram or endoscopy. The preoperative data was compared to the results at 2 years. Results: 396 patients underwent RAPR. The Median GERD-HRQL score was 42 (range 38 - 45) preoperatively and 6 (range 0 - 14) at two years (p < 0.05). Preoperatively 87% of patients were graded as Visick IV. At two years, 95% were graded as Visick I. HH recurrence occurred in 4/396 patients (1%). Conclusion: RAFR of HH is associated with excellent symptom relief and low recurrence rate. RAFR should be considered when deciding on what operation to perform in patients with large paraesophageal hiatal hernias.