Robotic-Assisted Repair of a Giant Para-Esophageal Hernia

Abstract Video Descrption This video highlights the steps of robotic-assisted repair of a giant para-esophageal hernia, as an aid to other embarking on such a surgery. We describe the case of a 63-year-old female who presented with anaemia, bloating, breathlessness, and post-prandial discomfort. Initially treated with iron and PPI, she subsequently underwent investigation with upper GI endoscopy and cross-sectional imaging, which demonstrated a giant mixed-type paraoesophageal hernia with Cameron ulceration, with pressure effects on the left main bronchus and atria, and compressive atelectasis. Following full work-up she underwent mesh repair of the hernia with fundoplication using the Da Vinci Xi™ robotic surgical platform. The video demonstrates the key principles of focusing on reduction of the sac rather than the contents, and the importance of predominantly blunt dissection with selective use of energy to safely separate the sac from surrounding structures. The da Vinci Xi™ platform facilitates excellent vision within the mediastinum, facilitating safe high esophageal dissection to ensure adequate intra-abdominal length. The use of Bio-A mesh strips reinforces the crural repair whilst avoiding impingement on the esophagus, and can be incorporated into the Toupet fundoplication at the right pillar. This case describes safe repair of a giant para-esophageal hernia via a robotic approach. The patient was discharged day one post-operatively, and subsequently progressed to a normal diet with resolution of her previous cameron ulceration and anaemia.