Operative trends and clinical outcomes of open, laparoscopic and robotic approaches to hiatal and paraoesophageal hernias- a study of 1834 patients.

Indications for the repair of hiatal and paraesophageal hernias (HH/PEH) have evolved considerably over the past two decades, largely driven by the growing adoption of minimally invasive surgical (MIS) techniques. This shift highlights the need to assess surgical trends and clinical outcomes associated with open (OPEN), laparoscopic (LAP), and robotic (ROBOT) approaches, particularly in cases involving large hernias, with more than 50% exhibiting intrathoracic gastric content. Understanding these trends is crucial as MIS continues to gain prominence in the management of complex cases, including large hernias. The aim of this study is to evaluate key outcomes during the transition from OPEN and LAP to ROBOT-assisted HH/PEH repair at a high-volume surgical center. This retrospective review examined 1,834 patients who underwent consecutive hiatal and paraesophageal hernia (HH/PEH) repairs-open (OPEN, n = 958), laparoscopic (LAP, n = 390), or robotic (ROBOT, n = 486)-between 2000 and 2023 at a large medical center. All patients were prospectively enrolled in an IRB-approved database. The study assessed trends in surgical technique, hernia size, and length of stay (LOS) over time. Additionally, patient demographics, the three most common preoperative symptoms, hernia type and size, surgical course, and clinical outcomes-including LOS, radiographic recurrence (evaluated by esophagrams at 3 and 12 months), reoperation rates, and postoperative symptom improvement-were also evaluated. Robotic surgery was introduced in 2018, with a steady annual increase in its use. The total number of operations performed also saw a significant rise over the study period. Mean hernia size decreased during the study, and the majority of patients (99.1%) presented with symptoms. Robotic surgery (ROBOT) demonstrated significantly superior symptom resolution compared to open surgery (OPEN) (p < 0.01), with this advantage sustained in patients with large hernias (p < 0.01). Additionally, length of stay (LOS) decreased over time. While the overall radiographic recurrence rate (8.6%) and reoperation rate (2.4%) were comparable across surgical techniques, ROBOT showed a higher radiographic recurrence rate for large hernias (18%, p < 0.01) without increase in reoperations. The volume of surgeries for HH/PEH repair has increased over time, driven by expanding surgical indications and advancements in minimally invasive and robotic techniques. Surgical intervention leads to significant improvements in HH/PEH symptoms, with more pronounced benefits seen in larger hernia cases. Minimally invasive surgery (MIS), particularly robotic surgery, demonstrates notable improvements in length of stay (LOS) and at least equivalent clinical outcomes when compared to traditional approaches. While the rates of anatomic recurrence and reoperation remain relatively low, ongoing evaluation-especially of robotic surgery-is essential to further minimize these occurrences.