Robotic surgery for treatment of hiatal hernia

Gastrointestinal and General Surgeons at Penn Medicine use minimally invasive, robotic approaches to treat hiatal hernia and the full spectrum of benign and malignant disorders of the esophagus, stomach, and upper small intestine. Linked to gastroesophageal reflux disease (GERD) and its complications, (i.e., Barrett’s esophagus), hiatal hernia is a precursor to gastrointestinal cancer.

Hiatal hernia types

In its simplest rendering, hiatal hernia occurs when a portion of the stomach with the gastroesophageal junction (GEJ) and the lower esophageal sphincter are pulled above the hiatus into the negative-pressure domain of the chest cavity.

Further complications involve the pathophysiology of hiatal hernia, which has four types. Type 1 (described above), the mildest and most common form of hiatal hernia, is termed sliding hernia because the GEJ of the stomach is sliding in and out of the hiatus. Types two, three, and four are termed paraesophageal hiatal hernias, and advance in complexity numerically. Type 2 manifests when the GEJ remains below the hiatus in its normal position but the curved upper fundus of the stomach rolls up into the hiatus; type 3 occurs when both the GEJ and the fundus have risen above the hiatus; type 4 presents when other organs of the GI tract have compromised the hiatus.

The patient experience: symptoms

Common symptoms of hiatal hernia include early satiety, bloating, belching, discomfort after eating, and dysphagia. In patients with progressed hiatal hernia, dyspnea and regurgitation of undigested food may occur.

Although GERD and heartburn are common causes of referral, these symptoms do not occur in all patients with hiatal hernia, and in those they do—particularly those in advanced stages—their effects tend to wane with time. Thus, symptomatic or not, all patients with severe chronic GERD—and particularly those with medically refractory GERD—are worked up at Penn GI Surgery to determine the cause.

Diagnosis of hiatal hernia

At Penn Medicine, patients with suspected or known hiatal hernia receive a series of evaluations to confirm the diagnosis, rule out other diagnoses, and define other potential contributors to GI distress. Depending upon the severity and type of hernia, these tests may include:

• An upper GI series (the “roadmap for the anatomy of hiatal hernia”) incorporating an esophageal swallow study;
• An upper GI endoscopy, or GI-EGD, to look for scarring, masses, and other mucosal irregularities in the esophagus;
• A biopsy for H. pylori, a potential source of stomach cancer;
• 24-hour pH impedance testing for acid and non-acid reflux in the esophagus;
• Manometry, which allows surgeons to evaluate the esophageal muscle function, and;
• A retroflection study, which allows surgeons to look back up toward the entrance of the stomach and the hiatus to assess the GE flap valve and the relationship between the diaphragm and GE junction.

Following diagnosis, treatment considerations begin.

The advance of robotic surgery for hiatal hernia

Penn Medicine surgeons provide the full spectrum of treatments for hiatal hernias at every stage. Robotic-assisted surgery is becoming the primary approach in many surgical specialties, and several Penn Medicine surgeons offer it for hiatal hernia and other forms of foregut disease.

The typical patient with a hiatal hernia undergoing robotic surgery at Penn Medicine will have a small to moderate symptomatic type 3 hiatal hernia that is unlikely to improve in the absence of surgery. Despite relative rarity, types 2 and 4 are seen at Penn GI Surgery because Penn Medicine is a regional referral center for foregut surgery.

Robotic surgeries for patients with symptomatic type 3 hiatal hernia have the objective of restoring the position of the stomach and hiatus and the function of the anti-reflux flap. Achieving these ends involves dissection of the dilated hernia from the mediastinum and returning the GEJ to the lower abdomen with an adequate esophageal span (~2.5-3.0 cm), particularly if fundoplication is planned.

A bolster against acid reflux, fundoplication involves wrapping and stitching the gastric fundus of the stomach around the GE junction, allowing recreation of the GE flat valve and angle of His—the angle formed between the lower end of the esophagus and the fundus of the stomach—and reinforcement of the lower esophageal sphincter.

Variants of the procedure include the Nissen procedure, in which the fundus is wrapped entirely around the esophagus, and the Toupet, or partial fundoplication, which encompasses 270 degrees; both reinforce the valve and prevent acid reflux.

The precision of robotic surgery is advantageous when maneuvering in a surgical environment that involves both the aorta, lying directly behind the esophagus, and the vagus nerve that controls esophageal function. Robotic instrumentation allows for the dissection and separation of the esophagus from the surrounding structures in the chest to permit enough length to avoid recurrence.

Recurrence is a common issue with hiatal hernia, but avoidance can be enhanced with careful planning and procedure. For example, a high circumferential dissection, including a posterior dissection between the aorta and the esophageal plane can minimize axial tension, the force that pulls the esophagus and stomach toward the mediastinum. This serves to prevent the GEJ from tethering and rising back up into the chest.

Minimally invasive hiatal hernia surgery at Penn Medicine

Minimally invasive hiatal hernia surgery is performed throughout the Penn Medicine health system by the following surgeons:

• Francis E. Rosato, MD, Sean P. Harbison, MD, MSEd, and Leslie M. Okorji, MD, at Penn Medicine University City
• Kristoffel R. Dumon, MD, at the Perelman Center for Advanced Medicine
• Maria Spassova Altieri, MD, MS, at Penn Washington Square and Penn Medicine Radnor
• Pamela Demnicki, MD, and Stefanie Haynes, DO, at Penn Surgical Specialists in Chester County, PA
• Arianne Train, DO, Zachary Ichter, DO, and William Hope, MD, at Penn Surgical Group in Lancaster, PA
• Brian Pellini, MD, Andrew Lambour, MD, and Justin Philip, MD, at Penn Medicine Doylestown Hospital specialize in repairing hiatal hernias

Referral and consultations

A referral for hiatal hernia evaluation is called for if a patient is symptomatic and an imaging finding (e.g., medically refractory reflux and a hiatal hernia on an upper GI endoscopy) is conclusive. This combination should prompt contact with a specialist who can determine if surgery or other treatments are warranted.

To refer a patient to the foregut surgery program, please call the Penn Medicine GI Surgery program in the Philadelphia region at 215-662-2626 or 717-544-3626 in Lancaster.