Keywords

Introduction

Gastroesophageal reflux disease (GERD) is a common affliction treated in most instances with over-the-counter antireflux medications, generic proton pump inhibitors (PPIs), and various combinations of these treatments. In the past, surgical interventions for uncomplicated GERD have been reserved for patients who have severe symptoms without relief over prolonged periods of treatment [7]. More recently, the cost of medical treatment and the detrimental effect of uncontrolled heartburn on quality of life, in certain instances, validate surgical management as a superior and more reliable alternative for patients. In addition, there are concerns regarding upper gastrointestinal tract cancer risks with prolonged use of PPIs [8, 9]. Minimally invasive operations for GERD are safe and relatively easily tolerated, with short hospital stays and minimal discomfort [3, 4]. Patients usually are able to return to work in most instances within 1–2 weeks for desk work and 4 weeks for more physically demanding work.

In certain instances, significant side effects have been noted with surgical interventions for GERD management. Nissen fundoplication (full, 360-degree wrap) and Toupet (partial, 270-degree wrap) surgical procedures have reliable, reproducible short-term and long-term results [10,11,12]. These procedures can be (and typically are) performed with minimally invasive techniques. Laparoscopic techniques result in promising outcomes in most cases, but recurrent symptoms of heartburn, dysphagia, stricture, and recurrent hiatus hernia requiring reoperation have been noted within 5 years in 25–35% of individuals in published literature [7, 13]. Vexing side effects of dysphagia (e.g., gas-bloat syndrome, an inability to belch or vomit) prevent many patients from pursuing surgical management.

The LINX® magnetic esophageal sphincter augmentation system (Torax Medical, St. Paul, MN) received approval from the US Food and Drug Administration (FDA) in 2013 [14,15,16]. LINX® is a considerably simpler, easier, and a more predictable surgical intervention for GERD management than Nissen or Toupet procedures. It is an outpatient procedure, with 95% of patients being discharged on the same day. Return to work is faster and postoperative restrictions are fewer. At 5 years, 95% of patients are off PPIs [14, 15]. There is minimal gas bloat, and patients are able to vomit. However, the novelty of the procedure and challenges with insurance coverage have hampered the adoption of LINX® placement as a standard procedure in most surgical centers (personal communication, 2015).

Robot-assisted operations for GERD yield results that are comparable to those of laparoscopic procedures—and, in some instances, better. Consequently, use of robotic technology by gastrointestinal surgeons has become more prevalent, especially in general surgery [17]. General surgeons have adopted the robotic technology to the point that general surgery is the fastest growing specialty using robotic technology [18,19,20]. Utilizing robotic surgical procedures is advantageous for a surgeon, as 3D visualization has strong advantages, especially for large paraesophageal hernias or more complicated anatomy. The instrumentation continues to improve, with staplers that are substantially easier to manipulate. The latest da Vinci® model XI (Intuitive Surgical, Sunnyvalle, CA) allows visualization of all abdominal quadrants with equal ease and definition [21, 22]. Such advancements in knowledge have changed the indications for robotic technology from operating on one focused area of the abdomen to equal visualization of all quadrants, which is required for many gastrointestinal procedures.

Preoperative Evaluations

Patients who have symptoms consistent with GERD should be carefully evaluated before considering operation. Heartburn-like symptoms do not necessarily come from acid reflux. Cardiac chest pain can be indistinguishable from heartburn. Heartburn that does not improve with medical management may not be reflux and may not improve if an antireflux procedure is performed. The patient may have a large hiatus hernia and partial outlet obstruction, which can present with similar GERD symptoms, such as chest pain. Gastritis, peptic ulcer disease, esophageal dysmotility, or even achalasia may present with similar symptoms. Thus, a clinical workup to prove GERD or determine the anatomy of the upper gastrointestinal tract is essential.

A barium upper gastrointestinal study provides important information about the anatomy and motility of the esophagus and stomach and will document GERD [23]. If gastroesophageal reflux is not seen on an adequate upper gastrointestinal tract study, GERD cannot essentially be eliminated, however, and additional testing must be performed to ascertain GERD.

The gold standard for documentation of GERD is the use of a pH probe or pH monitoring . This test gives a qualitative and a quantitative response as to the degree of reflux present, whether the reflux is postprandial, and the rate of acid clearance from the esophagus. Multichannel intraluminal impedance-pH monitoring is an alternative test that yields similar results but can also distinguish nonacid reflux [6].

Esophageal manometry is used in the workup of patients with presumed GERD. Manometry is especially important if patients have dysphagia and a symptom of heartburn or atypical symptoms with no evidence of reflux in the upper gastrointestinal tract. Patients with achalasia are often misdiagnosed with GERD before they undergo a complete workup. Such patients are often treated for reflux for extended periods before they undergo manometry.

Robotic Surgeries for GERD

Nissen Fundoplication

For a Nissen fundoplication, the patient is anesthetized in a normal supine position. After necessary lines are placed, the operating room table is shifted such that the patient’s head is away from the anesthesiologist and the tubing is tracked along the side of the operating table. Throughout the operation, the anesthesiologist remains at the foot of the OR table. Frequently, especially with patients who have comorbid conditions, arterial and venous monitoring lines are placed. The first trocar is placed 12 cm below the xiphoid and 4 cm to the left in women, and 15 cm below the xiphoid and 4 cm to the left in men. The reason for placement off the midline to the left is to be in line with the hiatus. The remaining trocars are placed in relation to the first trocar, which is the camera port. Two trocars are placed 4 cm cephalad and 8 cm to the left and right, on either side of the camera port. A separate trocar is placed below the right costal margin for liver retraction, and the last port is placed as an assistant port, to the left at a place suitable, usually laterally below the costal margin. These trocars are placed under direct laparoscopic control after the camera port has been placed. In addition, the liver retractor is placed laparoscopically.

The robot is then brought into the operative field and positioned using the camera port to center the robot. The patient is then placed in a reverse Trendelenburg position and the robotic arms are attached to the trocars, followed by introduction of the robotic camera. The operator subsequently proceeds to the robot and begins the operation. The surgical procedure starts with a dissection of the lesser curvature, exposing the right crus of the diaphragm (Fig. 33.1). Of note, mobilization of the esophagus and stomach off the diaphragm may be challenging in obese patients with excess upper abdominal fat. Afterward, the dissection continues along the anterior hiatus and left crus. Once the anterior diaphragm is cleared of all attachments to the esophagus, the dissection is carried posteriorly to free up the esophagus and stomach circumferentially (Fig. 33.2). At this stage, identification and preservation of the posterior vagus nerve is imperative (Fig. 33.3). Subsequently, the anterior vagus nerve is dissected off the esophagus with the associated gastroesophageal fat pad. It remains attached to the stomach at the gastroesophageal (GE) junction and provides a sling that assists in holding the wrap in position as the fundoplication is brought under the dissected anterior vagus (Fig. 33.4). It is important to dissect the gastroesophageal fat pad, as this dissection defines the GE junction and clears it of any fat, which may cause the wrap to loosen or even slip over time (Fig. 33.5).

Fig. 33.1
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Dissection of the lesser curvature. A, Right crus. B, Esophagus. C, Hernia sac over left crus

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Fig. 33.2
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Dissection carried posteriorly to free up the esophagus and stomach. A, Posterior junction of the left and right crura. B, Esophagus

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Fig. 33.3
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Closure of diaphragm with preservation of the posterior vagus nerve (arrow). A, Esophagus without dilator.

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Fig. 33.4
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‘Sling’ of anterior vagus to prevent slipping of the wrap (arrow). A, Right-sided fundus beneath the sling. B, Esophagus. C, Left-sided fundus

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Fig. 33.5
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Gastroesophageal (GE) junction with gastroesophageal fat pad and hernia sac (arrow). A, Hiatal hernia cavity. B, Residual gastroesophageal fat pad and hernia sac

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If the esophagus is foreshortened, it must be mobilized in the mediastinum. This dissection is performed more easily with the robot than with a laparoscopic approach. The 3D visualization of structures provided by robotic technology results in a more meticulous dissection. The goal of the mediastinal dissection is to provide at least a 3-cm length of esophagus in the abdomen inferior to the hiatus, without requiring tension to hold it there. Once this dissection is completed, the short gastric vessels must be divided to mobilize the fundus enough to wrap around the esophagus without tension. The number of short gastric vessels that need to be divided may vary depending on the individual’s anatomy, the size of the hernia, and the volume of stomach contained in the hernia sac (Fig. 33.6).

Fig. 33.6
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Division of short gastric vessels. A, Left crus. B, Esophagus. C, Fundus of stomach after removal of short gastric vessels

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After clearing of the hiatus and adequate mobilization of the esophagus and the fundus of the stomach, the hiatus must be repaired. Dissection of the hiatus itself creates a larger defect, and dissection of the phrenoesophageal ligaments results in fewer attachments to retain the esophagus in place. The fundoplication itself assists with holding the esophagus below the diaphragm and with closing the hiatus.

Repair of the diaphragm is performed over a dilator. The size of the dilator generally ranges from 50 to 60 Fr and should be chosen with the patient’s size and body habitus in mind. Surgeons’ preferences generally determine the size of the dilator; there is no “one size fits all” paradigm. It is imperative to have an experienced anesthesiologist pass the dilator. It is also important that the surgeon and anesthesiologist work in tandem during the passing of the dilator to ensure that the surgeon is aware of the dilator’s visibility as it moves through the hiatus. Perforating the esophagus with the dilator is a catastrophic complication that is always avoidable if care is taken.

Once the dilator is in place, the hiatus can be closed (Fig. 33.7). This suturing is significantly easier with the robot than suturing with laparoscopic technology. Stitches can be placed similarly to those during an open technique. A figure-of-eight suture is more secure than single stitches (Fig. 33.8). In addition, this process ensures minimal muscle manipulation, thereby making certain that the muscle is not shredded. If possible, the peritoneum attached to the diaphragm should be left attached to the crura to prevent shredding of the crural muscle. If the hiatus defect is large or the crura are thin, then pledgets are helpful to provide additional strength to the closure. If pledgets are to be used, the suturing method should be slightly different. Instead of a figure-of-eight closure, a “U”-type stitch should be used, which will provide a more secure closure (Fig. 33.9). Additionally, reinforcement with an onlay biologic mesh has been reported to decrease the incidence of hernia recurrence [24]. Biologics should not be used as a bridge because of eventration of the mesh over time. Permanent mesh must be used judiciously, as it may cause erosion of the esophagus.

Fig. 33.7
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Closure of the hiatus

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Fig. 33.8
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Closure of the diaphragm with figure-of-eight stitches

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Fig. 33.9
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Teflon pledgets and ‘U’ stitch (arrow) to compress the crura together

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If the intra-abdominal esophagus appears to be short of the required 3 cm after the maximum length of the esophagus has been obtained by mobilizing the esophagus in the mediastinum, it is prudent to first repair the diaphragm and then determine whether any further length of intra-abdominal esophagus is required. As the diaphragm is dome-shaped, the anterior hiatus is cephalad to the posterior hiatus, and closing the hiatus pushes the esophagus into an anterior position, which in many instances is the 2–3 cm cephalad required. If the esophagus still has no significant length in the abdomen, then a Collis gastroplasty should be performed. Collis gastroplasty for a foreshortened esophagus will decrease the incidence of a recurrent hiatus hernia.

Fundoplication is initiated by placing a clamp behind the esophagus at the diaphragm, followed by passing the fundus to the clamp. Subsequently, the fundus is passed beneath the anterior vagal sling to prevent the wrap from slipping down onto the stomach. The portion of the fundus, which remains on the patient’s left side, is grasped and brought up to the fundus from the right side. Stitches are then placed 1 cm apart to make a 3-cm wrap. Every stitch includes left fundus, esophagus, and right fundus. The fundus can then be tacked to the diaphragm in several places to prevent development of a recurrent hernia (Fig. 33.10).

Fig. 33.10
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Suturing of the right fundus to the right crus to prevent slipped wrap

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There are several keys to a successful, durable fundoplication:

  • Adequate workup to evaluate the patient, to make an accurate diagnosis and exclude contraindications for a Nissen fundoplication

  • Mobilization of the esophagus and proximal stomach to have 3 cm of esophagus below the diaphragm without tension

  • Removal of the gastroesophageal fat pad

  • Adequate closure of the diaphragm over a 50–60 Fr dilator

  • Preservation of the anterior and posterior vagus nerves

  • Using biological mesh for the closure of the hiatus (if necessary) as an onlay, not as a bridge

  • Judicious use of synthetic mesh to repair the hiatus, in order to prevent erosion into the esophagus

Paraesophageal Hiatus Hernia Repair and Nissen Fundoplication

Repair of a paraesophageal hiatus hernia can be challenging, as it is associated with a higher recurrence rate and more complications. Paraesophageal hernias are also usually larger than sliding hernias, and robotic technology has both advantages and disadvantages for repair of large hernias. There have been several classifications of paraesophageal hernias, which are helpful to consider during planning the surgical procedure. That being said, the basic principles of repair of large and small hernias are essentially the same. The entire hernia sac must be taken down from the chest cavity (Fig. 33.11). Mobilization of the esophagus is important. The anterior and posterior vagus nerves must be dissected and preserved. At the beginning of the dissection, the peritoneum at the anterior hiatus is grasped and pulled away from the diaphragm, followed by opening and clearing off of the hiatus. In doing so, a plane is developed between the hernia sac and mediastinal structures such as the pericardium and pleura (Fig. 33.12). If the hernia is very large, the esophagus as well as the apex of the mediastinum can be visualized by pulling down on the peritoneum and bluntly dissecting the hernia sac off the pericardium. By pulling down on the peritoneum, the stomach comes down with the hernia sac. Subsequently, lateral and posterior dissection should be continued in the same plane. Vascular structures on the right crus should be identified in this dissection. Left gastric vessels are usually pulled up into the chest with the stomach (Fig. 33.13). While taking down the hernia sac along the right crus, care must be taken to ensure that the dissection remains in the same plane. If the left gastric artery is erroneously cut, the vessel may retract into the chest, especially if attachments to the hernia sac have not been dissected. A similar error can be made on the left crus, as the short gastric vessels are likewise pulled into the hernia sac.

Fig. 33.11
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Large paraesophageal hiatus hernia (arrow). A, Course of left gastric vessels through the hiatus

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Fig. 33.12
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Paraesophageal hernia sac (arrow). A, Left crus. B, Pericardium

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Fig. 33.13
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Left crus (arrow). A, Edge of posterior hernia sac. B, Aorta. C, Left gastric vessels

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Partial Fundoplication: 270-Degree Fundoplication (Toupet Procedure) and Dor Fundoplication (Anterior Partial Fundoplication)

Patients with dysphagia and reflux symptoms require careful evaluation. GERD with resultant Barrett’s esophagus increases the risk of adenocarcinoma of the esophagus [25,26,27]. If a patient with known Barrett’s develops dysphagia, the initial diagnosis to be ruled out is esophageal cancer. Other causes of dysphagia in this group of patients are peptic strictures and esophageal dysmotility [28]. Diagnostic endoscopy is important to rule out these diagnoses. Endoscopy can also be therapeutic in patients with stricture, as a dilation can be performed to make a treatment decision regarding improving medical management versus proceeding with surgical management. Once cancer and esophageal stricture have been ruled out, patients should undergo esophageal manometry to determine the presence of esophageal dysmotility. This thorough workup will reduce the likelihood of operating for a GERD diagnosis when a complete evaluation might show dysmotility or achalasia.

Partial fundoplication is indicated in patients with esophageal dysmotility. The Toupet procedure is similar in all respects to a full-wrap Nissen fundoplication, except that the fundus, after being brought around behind the esophagus, is sutured at the 10 o’clock position of the mobilized esophagus with three stitches over a length of 3 cm. Additionally, the left side of the wrapped fundus is sutured to the esophagus at the 2 o’clock position, thereby leaving the anterior esophagus unincorporated in the wrap (Fig. 33.14). The result is reduced pressure on the esophagus at the GE junction and reduced dysphagia, while GERD is still controlled. Several series have reported satisfactory long-term results with the Toupet procedure when compared with a full wrap, even in patients who do not have dysphagia or esophageal dysmotility [11, 29].

Fig. 33.14
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Completed partial fundoplication with sutures at 10 o’clock and 2 o’clock

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A major advantage of the robotic technology is the similarity of suturing ability to an open case. This is true for both Toupet and Dor fundoplication procedures. The Dor fundoplication is most commonly used for patients with achalasia undergoing a Heller esophageal myotomy. The reported incidence of severe reflux with Heller myotomy is 30–50% in peer-reviewed literature [30]. With an anterior fundoplication, the incidence decreases to about 9–14%, and postprocedural reflux is usually relatively easy to control with medications [30]. Published reports indicate promising results with a Dor fundoplication for GERD, with fewer of the severe side effects of a Nissen [31, 32].

Dor fundoplication is an easier procedure than either a full wrap or 270-degree wrap because the short gastric vessels do not need to be divided. After mobilization of the esophagus and closure of the hiatus, the anterior fundus is grasped and stitches are placed through the full-thickness gastric fundus to the anterior esophagus 3–4 cm above the GE junction. Stitches are then placed to cover almost 50% of the anterior esophageal wall. The fundus is not attached to the posterior esophagus.

Collis Gastroplasty

Large paraesophageal hiatus hernias are often associated with a foreshortened esophagus. As a consequence, after hiatus hernia reduction, mobilization of the mediastinal esophagus, removal of the hernia sac, and closure of the hiatus, the esophagus still might not be visible in the abdomen, or it appears only minimally below the diaphragm. In this case, there are two options. One is to perform a gastropexy to hold the stomach in the abdomen. Unfortunately, gastropexy by itself has the potential of worsening GERD. A gastropexy creates an upside-down funnel, which may hold the GE junction open and cause severe reflux. This problem can be prevented by a modified Hill procedure, which imbricates circular fibers of the GE junction at the hiatus, with stitches that include both anterior and posterior cardia. The GE junction is then attached to the diaphragm. The Hill repair is usually not recommended for routine hiatus hernia repairs because of unacceptable recurrent symptoms.

The second option is a Collis gastroplasty. The recurrence rate for repair of large paraesophageal hernias is unacceptably high if the esophagus cannot be brought into the abdomen with at least 3 cm inferior to the diaphragmatic hiatus. If there is sufficient length without tension on the esophagus, a standard Nissen or Toupet can be performed. If <3 cm of esophagus is below the diaphragm, a Collis gastroplasty will reduce the risk of recurrent hernia [33]. Collis gastroplasty is an esophageal lengthening procedure, accomplished by taking a wedge out of the cardia of the stomach on the greater curvature side of the esophagus. Thus, when the fundus is wrapped around esophagus, in reality it is actually being wrapped around the residual cardia. This can be accomplished because only 2–3 cm of the cardia of the stomach is in the wrap, and the peristalsis of the esophagus above the wrapped cardia is carried passively through the wrap.

Collis gastroplasty can be performed robotically with special staplers available for robotic cases. These staplers are very functional and superior to the handheld stapler used by an assistant through a left lateral port. The procedure is similar to the paraesophageal hiatus hernia repair with a Nissen fundoplication, until the closure of the diaphragm. If the esophagus cannot be brought into the abdomen for 3 cm without tension, then a Collis gastroplasty should be considered. At this point, a dilator should be placed into the stomach to prevent narrowing of the “neo-esophagus” (Fig. 33.15). A 45-mm green-load stapler, which is easiest to manipulate in the upper abdomen, is brought into the abdomen and placed across the greater curvature near the cardia. The second staple load along the same line as the first load will approach the previously positioned dilator (Fig. 33.16). The third staple load should begin in the “crotch” of the stapled stomach and the dilator (Fig. 33.17).This load is oriented parallel with the dilator and in a cephalad direction. Subsequently, a fourth staple load may be required, which completes the wedge gastric resection (Fig. 33.18). Presently, the fundus is brought around the esophagus with the dilator in the esophagus. Afterward, the left-sided fundus is brought up and sutured to the right fundus with three stitches to complete the wrap (Figs. 33.19 and 33.20).

Fig. 33.15
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Hiatus closure with dilator in the esophagus

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Fig. 33.16
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Collis gastroplasty procedure with two staple lines placed with a 45-mm green-load Echelon™ stapler (Ethicon; Somerville, NJ). A, Remaining cardia. B, Fundus of the stomach

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Fig. 33.17
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Robotic stapler placed across the cardia parallel to the esophageal dilator (arrow)

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Fig. 33.18
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Stapler completes the gastric wedge resection

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Fig. 33.19
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Completion of the Collis gastroplasty wrap. A, Staple line on cardioesophageal junction. B, Staple line on remaining fundus pulled around behind the esophagus. C, Body of the stomach

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Fig. 33.20
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Third stitch of Nissen fundoplication over a Collis gastroplasty. A, Right-side fundoplication. B, Left-side fundoplication

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Robotic Operations for Recurrent Hiatus Hernia and Recurrent GERD and Complications of Hiatus Hernia Repair

Repeat surgical procedures of any kind are usually more difficult and challenging than the initial procedures. Reoperations for esophageal diseases are even more challenging, because exposure of the esophagus can be very difficult (Fig. 33.21). Additionally, an esophageal injury during the surgical procedure in the chest or mediastinum may require a thoracic approach to correct the problem. Recurrent hiatus hernia, in which the stomach or fundoplication are wedged into the hiatus and partially in the chest, demands a careful evaluation with an understanding of the altered anatomy (Figs. 33.22 and 33.23). It is necessary to have a well-thought-out plan and a clear justification for pursuing a laparoscopic, robotic, or open approach (Fig. 33.24). A general surgeon who decides to undertake a thoracic approach must confer with a thoracic surgeon. All possible surgical options must be explored, especially if a thoracic or thoracoscopic approach may be needed (Fig. 33.25).

Fig. 33.21
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Adhesions covering esophagus and fundoplication

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Fig. 33.22
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Recurrent hiatal hernia. A, Right crus. B, Sutures from previous hiatal hernia repair. C, Esophagus. D, Fundus

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Fig. 33.23
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Recurrent hiatal hernia. A, Left crus. B, Gastric wall with adhesions

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Fig. 33.24
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Complications of hiatal hernia repair. A, Slipped and separated fundoplication. B, Esophagus with myotomy (arrow). C, Diaphragm

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Fig. 33.25
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Reapproximation of fundoplication. A, Diaphragm. B, Esophagus. C, Fundoplication

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When compared with a laparoscopic approach, a robotic approach presents the advantages of superior visualization and easier suturing. One of the disadvantages with the robotic procedure is lack of tactile sensation and feel for the tissue (haptic sensation). In most cases, dense adhesions are present, and it is relatively easy to tear tissue. Another less obvious disadvantage with the robotic technology is that, despite better local visualization, the view is extremely focused, thereby leading to a lack of a “big picture” view. It may be difficult to know the exact location within the esophagus with such a limited (albeit focused) view during the surgical procedure.

The objective of operations for recurrent GERD or recurrent hiatus hernia with or without obstruction should be reestablishment of normal anatomy. This goal may require reduction of a hernia, reclosing the hiatus, and repeating the fundoplication if the initial repair has slipped or come apart. In turn, an alteration in the planned procedure may be required if there is an injury to the esophagus or stomach. If the repeat surgical procedure is a third or fourth operation and there is an esophageal injury above the fundoplication, with remaining dissection equally challenging, it is recommended to pursue a thoracic approach to repair the esophagus, followed by completion of the fundoplication. An alternative approach might be resection of the distal esophagus above the perforation to bring up the stomach, followed by resection of the cardia and fundus. An anastomosis of the esophagus to the body of the stomach would complete this procedure, but symptom reduction cannot be guaranteed with a repeat procedure and patients may continue having reflux symptoms.

If all surgical options have been exhausted, the surgeon might offer an esophagojejunostomy with Roux-en-Y [34, 35]. This procedure requires a thorough and informative discussion with the patient, followed by obtaining a written informed consent prior to the surgery. It should be considered a last resort after all other options have failed. The anatomy and adhesions are predictably difficult, and the goal should be to eliminate reflux. The esophagojejunostomy accomplishes this. The length of the Roux-en-Y limb should be longer than the usual 40 cm, to ensure that the patient does not continue to reflux.

Conclusion

Robotic surgical procedures have become essential for successful completion of complex, minimally invasive operations, and such technologies have found their place in the operative armamentarium of many more specialties and surgeons. The role of robotic technology for general surgeons is yet to be defined in its entirety, and in this age of limited funds and health-care reform, robotics in surgery is under intense scrutiny by health-care systems and payors. Surgeons with experience in this field must implicitly contribute to the discussions with various stakeholders to ensure that a well-thought-out plan is implemented to provide superior, value-based care to our patients.