Redo hiatal hernia surgeries: Robotic thoracoscopic approach

Background: Redo procedures in hiatal hernia surgeries tend to be more complex due to adhesions and altered anatomy. We developed a safe and effective robot-assisted minimal-invasive transthoracic repair that holds concepts of Belsey's technique for situations when the abdomen is inaccessible and a transthoracic approach remains as last resort. Belsey Fundoplication: The Belsey mark IV fundoplication consists of a posterolateral thoracotomy trough the sixth intercostal space. The fundoplication is created by placing three mattress sutures to form a 240° anterior wrap. A second row of three mattress sutures are then placed and sufficient crus sutures are tied to complete the procedure. Development of a Robotic Thoracoscopic Redo Procedure: The positioning, trocar placement, and feasibility were explored in several embalmed and fresh frozen human cadavers. We determined that the optimal position is when the patient is in a right lateral decubitus position with an additional 45-degree rotation ventrally. Determining optimal trocar placement remains patient tailored and we advise to place the trocars in a configuration that resembles the Y-figure. Conclusion: Robot-assisted transthoracic redo antireflux surgery (RATAS) is technically feasible in adult human cadavers using four ports. Preliminary results show symptom relief in about two-thirds of the patients. With these results we recommend considering a robot thoracic approach in a highly selected patient group when the abdominal cavity is inaccessible.