ORIGINAL ARTICLE

pISSN 2234-778X • eISSN 2234-5248

J Minim Invasive Surg 2023;26(3):1-12

Robotic-assisted versus laparoscopic paraesophageal

hernia repair: a systematic review and meta-analysis

Symeonidou Elissavet, Gkoutziotis Ioannis, Petras Panagiotis, Mpallas Konstantinos,

Kamparoudis Apostolos
5th Department of Surgery, Ippokratio General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

Purpose: The robotic approach offers improved visualization and maneuverability for Received Mon D, 2023
Revised Mon D, 2023
surgeons. This systematic review aims to compare the outcomes of robotic-assisted and Accepted Mon D, 2023
conventional laparoscopic approaches for paraesophageal hernia repair, specifically
examining postoperative complications, operative time, hospital stay, and recurrence. Corresponding author
Symeonidou Elissavet
Methods: A systematic review including thorough research through PubMed, Scopus, and 5th Department of Surgery, Ippokratio
Cochrane, was performed and only comparative studies were included. Studies concerning General Hospital, Aristotle University
of Thessaloniki, Konstantinoupoleos
other types of hiatal hernias or children were excluded. A meta-analysis was conducted to 49, Thessaloniki 54642, Greece
compare overall postoperative complications, hospital stay, and operation time. E-mail: ellie.simeonidou@gmail.com
https://orcid.org/0000-0001-7297-841X
Results: Ten comparative studies, with 186,259 participants in total, were included in the
meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It
appeared that there is no statistically significant difference between the conventional
laparoscopic and the robotic-assisted approach, regarding the overall postoperative
complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28–1.11), the mean
operation time (t = 1.41; 95% CI, –0.15–0.52; p = 0.22), and the hospital length of stay (t =
–1.54; degree of freedom = 8; 95% CI, –0.53–0.11; p = 0.16). Only two studies reported
evidence concerning the recurrence rates.
Conclusion: Overall, the robotic-assisted method did not demonstrate superiority over
conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative
complications, operation time, or hospital stay. However, some studies focused on cost and
patient characteristics of each group. Further comparative and randomized control studies with
longer follow-up periods are needed for more accurate conclusions on short- and long-term © 2023 The Korean Society of Endo-
Laparoscopic & Robotic Surgery
outcomes. This is an open access article under
the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-
nc-nd/4.0/).
Keywords: Paraesophageal, Hiatal hernia, Laparoscopic, Robotic, Mesh

INTRODUCTION in many abdominal procedures, including hiatal hernia repair

since it is associated with less postoperative pain, easier mo-
Minimal-invasive surgery has become the treatment of choice bilization of the patient, and shorter hospital lengths of stay.

Journal of Minimally Invasive Surgery Vol. 26. No. 3, 2023 https://doi.org/10.7602/jmis.2023.26.3.1

Last named et al.

Laparoscopic hiatal hernia repair is a time-consuming and tech- METHODS

nically demanding procedure, commonly accepted to have two
major disadvantages; the lack of depth perception because
of the two-dimensional imaging, and limited maneuverability.
On the other hand, the robotic-assisted approach offers better
ergonomic conditions, a three-dimensional view, better access
to the mediastinum, and a wide range of motions, wrist-like
movements of the instruments, significantly useful for suturing
or mesh placement, but it is also associated with a higher cost.
The aim of this systematic review and meta-analysis is to find
out whether robotic-assisted paraesophageal hernia repair is
superior to conventional laparoscopic in terms of morbidity and
operation time, and therefore worth the cost. The PICO criteria
were used in order to conduct the scientific question: Is the
robotic approach (Intervention) superior to laparoscopic (Com-
parison) in male and female patients with hiatal hernia, who are
older than 18 years (Population), in terms of postoperative com-
plications, length of stay (LOS), operative time and recurrence
rates (Outcomes)?
Eligibility criteria
Inclusion criteria
Only comparative studies of robotic and laparoscopic para-
esophageal hernia repair in adults were included in the study.
Exclusion criteria
Case reports, small case series, articles not in the English
language, as well as articles concerning patients younger than
18 years old were excluded from the study. In addition, articles
about other types of diaphragmatic hernia repair like Morgagni,
Bochdalek, iatrogenic, and postesophageal, are excluded from
this study.
Search strategy
From December 1, 2022 to December 31, 2022, a comprehen-
sive literature search of MEDLINE, Scopus, and the Cochrane
Library was conducted, using the keywords robotic AND lapa-
roscopic AND hernia AND (hiatal OR paraesophageal OR dia-
phragmatic). The evaluation of the studies was performed by

Identification of studies via databases

Records removed before screening

Identification

Duplicate records removed

Records identified from
(n = 60)
PubMed (n = 131)
Records conderning pediatric
Scopus (n = 108)
population (n = 13)
Cochrane (n = 5)
Records not in the English
language (n = 4)

Records excluded (case reports

Records screened
and small case series)
(n = 167)
(n = 20)

Reports not retrieved (other types

Reports sought for retrieval of diaphragmatic hernia like
Screening

(n = 147) Morgagni, bariatric surgery, narrative

reviews, special circumstances)

Reports excluded:
Reports assessed for eligibility
Only robotic-assisted (n = 20)
(n = 34)
Only laparoscopic (n = 4)

Fig. 1. Flow chart of the search

strategy algorithm and the data
extraction according to PRISMA
Included

Studies included in review (Preferred Reporting Items for

(n = 10) Systematic Reviews and Meta-
Analyses) guidelines.

2 https://doi.org/10.7602/jmis.2023.26.3.1
 Robotic-assisted versus laparoscopic paraesophageal hernia repair

two reviewers who worked independently. Cohen’s kappa was

p -value

0.749
0.005
0.765
0.001
calculated at 98.6%, indicating an almost perfect level of agree-

0.05
0.8
ment [1]. The search strategy algorithm and the data extraction
are illustrated in Fig. 1. Most of the studies included in this sys-

0.51 (0.31–0.85)
0.82 (0.29–2.37)
0.24 (0.08–0.75)
0.28 (0.13–0.63)
1.21 (1.14–1.29)
0.68 (0.05–8.5)
OR (95% CI)
tematic review are single-center retrospective studies or obser-
vational cohorts selected from databases where the data were
registered prospectively. No randomized control studies are
reported in the literature. For this reason, the risk of bias in lit-
erature, unfortunately, exists, especially regarding indication and

Robotic
Overall postoperative

1
9
1,321
16
6
5
selection bias. The design of the study was performed accord-

complications (n)
ing to the PRISMA (Preferred Reporting Items for Systematic
Reviews and Meta-Analyses) 2020 guidelines. No automation

Laparoscopy
tools were used. The study focuses on the hiatal hernia repair,

2
29
17,843
250
11
15
not the fundoplication technique.

Statistical analysis
IBM SPSS version 29.0 (IBM Corp.) was used for the meta-

Robotic
12
142
9,897
835
55
16
analysis and the results are presented in Forest plots. Egger

Participants (n)
test was used to estimate publication bias, which is illustrated
in funnel plots. Any missing results were excluded from the

Laparoscopy
17
151
158,432
6,774
85
42
analysis. The ReviewManager (RevMan) calculator version 5.2,
a useful tool provided by the Cochrane Library, was used to
estimate missing standard deviations in cases of continuous
variables. The random effects model was used for continu-
Single-center retrospective analysis
Single-center retrospective analysis

Single-center retrospective analysis

Single-center retrospective analysis
ous or binary variables and the effect was considered statisti-

Retrospective database analysis

Retrospective database analysis
cally significant when the p -value was below 0.05, with a 95%
confidence interval (CI). Cohen’s d, the standardized mean
Study design

difference was used for the effect size of continuous variables.

Sidik-Jonkman estimator with Knapp-Hartung adjustment was
applied [2].
The overall postoperative complications, the mean operation
time, the hospital LOS, the estimated blood loss, and the recur-
rence rates, are the outcomes intended to be studied in this re-
view. The data collected from the studies included in the review
Table 1. Data for postoperative complications

2019 United States

2020 United States
2020 United States

Tjeerdsma et al. [8] 2022 United States

are presented in Tables 1, 2, and 3.

Nation

2012 Germany

2021 Germany

RESULTS
OR, odds ratio; CI, confidence interval.

Only six studies provided enough evidence about the overall

Year

postoperative complication rates, as illustrated in Table 1.

Ward et al. [3] published the study with the most participants,
Hosein et al. [22]
Soliman et al. [4]

Benedix et al. [5]

from the National Inpatient Sample database during the time

Ward et al. [3]
Gehrig et al. [7]

period 2010–2015, and reported that the complications in the

robotic group were significantly higher odds ratio (OR) (1.17;
95% CI, 1.07–1.27), and specifically respiratory failure (OR, 1.68;
Study

95% CI, 1.37–2.05) and esophageal perforation (OR, 2.19; 95%

https://doi.org/10.7602/jmis.2023.26.3.1 3
4
Table 2. Data for the length of stay, the estimated blood loss, and the recurrence rates
Last named et al.

Study Participants (n) Length of stay (day) Estimated blood loss (mL) Recurrence rates (%)a)
Study Year Nation
design Laparoscopy Robotic Laparoscopy Robotic p-value Laparoscopy Robotic p-value Laparoscopy Robotic p-value
Gehrig 2012 Germany Single-center 17 12 6.5 ± 1.6 7.8 ± 3.9 0.272 24 ± 42 33 ± 85 0.742
et al. [7] retrospective (IQR, 5–10) (IQR, 5–19) (IQR, 0–150) (IQR, 0–300)
analysis
Soliman 2019 United Single-center 151 142 1.8 ± 1.5 1.3 ±1.8 0.003
et al. [4] States retrospective
analysis
O'Connor 2020 United Single-center 278 114 3.3 2.3 0.003 32.8 13.3 0.008
et al. [9] States retrospective
analysis
Gerull 2020 United Retrospective 1,024 830 2.9 ± 1.4 1.8 ± 0.6 0.001 89.3 ± 27.8 27.3 ± 5.9 0.001
et al. [10] States database
analysis
Hosein 2020 United Retrospective 6,774 835 3.9 3.44
et al. [22] States database
analysis
Kulshrestha 2021 United Retrospective 5,962 1,520 2 3 0.001
et al. [28] States database (IQR, 1–4) (IQR, 2–5)
analysis
Benedix 2021 Germany Single-center 85 55 4 3.6 0.2 44.2 57.2 0.25
et al. [5] retrospective (3.8–4.2) (3.4–3.8)
analysis
Lekarczyk 2022 United Single-center 42 31 2.55 2 0.09
et al. [27] States retrospective
analysis
Tjeerdsma 2022 United Single-center 42 16 2.5 (1–4) 3 (2–5.75) 0.301
et al. [8] States retrospective
analysis
IQR, interquartile range.
a)
One-year follow-up.

https://doi.org/10.7602/jmis.2023.26.3.1
 Robotic-assisted versus laparoscopic paraesophageal hernia repair

Table 3. Data for operation time

Laparoscopic Operation Robotic Operation
Study Year Nation Study design p -value
(n) time (min) (n) time (min)
Gehrig 2012 Germany Single-center 17 168 ± 42 12 172 ± 31 0.785
et al. [7] retrospective analysis (IQR, 130–290) (IQR, 115–120)
Soliman 2019 United Single-center 151 158 142 186.5 0.001
et al. [4] States retrospective analysis (IQR, 132–188) (IQR, 152–232)
O'Connor 2020 United Single-center 278 175 114 179 0.681
et al. [9] States retrospective study
Gerull 2020 United Retrospective database 1,024 187.3 ± 65.3 830 174.1 ± 63.8 0.001
et al. [10] States review
Benedix 2021 Germany Single-center 85 125 ± 35.5 55 149 ± 42.1 0.01
et al. [5] retrospective analysis
Lekarczyk 2022 United Single-center 42 256.7 31 257.6 0.48
et al. [27] States retrospective analysis
IQR, interquartile range.

CI, 1.42–3.93), even in high volume centers. On the other hand,
Soliman et al. [4] reported that older age and laparoscopic
approach were associated with more postoperative complica-
tions, but it was not a randomized study. Meta-analysis for cat-
egorical data was performed, according to the meta-analysis,
there was no statistically important difference considering the
overall postoperative complications rates between laparoscopic
and robotic hiatal hernia repair. A random effects model was
applied; OR, 0.56 (95% CI, 0.28–1.11), without any statistical sig-
nificance. A p -value for Egger was 0.24, indicating statistically
significant publication bias, with considerable heterogeneity.
This is explained by the fact that four of the studies included in
the meta-analysis are retrospective single-center studies with
a smaller number of participants and the rest of the studies are
database studies with a much bigger number of participants.
Sensitivity analysis could not be performed because multiple
studies have similar weights. The results of the meta-analysis
are interpreted in Fig. 2A and the funnel plot in Fig. 3A.
Some of the most frequent complications are dysphagia,
pleural effusion [5], pneumonia, venous thromboembolism, car-
diac failure [3], atrial fibrillation [6], atelectasis, delayed gastric
emptying, wound infections [7], thoracic or abdominal infections
[6], and mediastitis.
Regarding intraoperative complications, the most common
are bleeding [5], perforation [8], and pneumothorax [7]. The
important information missing from the majority of the studies
is the type of fundoplication used and whether a mesh was
placed or not.
Another area of interest is whether robotic-assisted hiatal
hernia repair is related to shorter hospital LOS. Nine out of 10
studies provided data about the LOS, as shown in Table 2.
There was no statistically significant publication bias (p for
Egger test = 0.073; 95% CI, –0.913 to 0.550), as shown in the
funnel plot (Fig. 3B). According to the meta-analysis, as illus-
trated in Fig. 2B, there is no statistical significance considering
the LOS between the robotic and the laparoscopic approach
(t = –1.54, degree of freedom (df) = 8; 95% CI, –0.53 to 0.11; p
= 0.16). However, there is a significant heterogeneity (I2, 97%),
especially between single-center studies with a smaller number
of participants and database studies, where a bigger number
of participants is included. Sensitivity analysis could not be per-
formed because multiple studies had similar weights.
Although the meta-analysis proved equivalent results regard-
ing the LOS, a considerable number of studies, as shown in
Table 2, reported shorter hospitalization in the robotic group. A
different adaptation of ERAS (Enhanced Recovery After Sur-
gery) protocols might be the explanation for this fact [9].
Concerning the mean operation time, only six studies pro-
vided information about this outcome, as indicated in Table 3.
There is no significantly important difference concerning the
operation time between robot-assisted and laparoscopic hiatal
hernia repair (t = 1.41, df = 5; 95% CI, –0.15 to 0.52; p = 0.22) (Fig.
2C). Regarding publication bias, p for Egger test = 0.921, so
there is no significant important publication bias, as illustrated
in the funnel plot (Fig. 3C). However, it should be noticed that
the operation time might decrease over time, as for example
mentioned by Benedix et al. [5], as the surgeons become more
experienced. This notice might consist of a learning curve bias,

https://doi.org/10.7602/jmis.2023.26.3.1 5
Last named et al.

Effect size of each study Confidence interval of effect size

A Estimated overall effect size Overall effect size value
No-effect value Estimated overall confidence interval

Forest plot

Study Lower Upper p-value Weight Gehrig 2012

OR
95% CI 95% CI
Soliman 2019
Gehrig 2012 0.68 0.05 8.90 0.765 0.60
Soliman 2019 0.28 0.13 0.63 0.001 6.20 Ward 2020
Ward 2020 1.21 1.14 1.29 0.005 1,067.50
Hossein 2020
Hossein 2020 0.51 0.31 0.85 0.05 14.73
Benedix 2021 0.82 0.29 2.37 0.8 3.43 Benedix 2021
Tjeerdsma 2022 0.31 0.17 0.57 0.749 10.74
Tjeerdsma 2022

Overall 0.56 0.28 1.11 Overall

0 1 2 3 4 5 6 7 8 9

Effect size of each study Confidence interval of effect size

B Estimated overall effect size Overall effect size value
No-effect value Estimated overall confidence interval

ID Cohen s d Lower Upper Weight Weight (%) 0.212944

Gehrig 2012 0.47 0.28 1.22 3.42 6.60

Soliman 2019 0.30 0.53 0.07 6.26 12.22
O'connor 2020 0.33 0.55 0.11 6.32 12.32
Gerull 2020 0.99 1.08 0.09 6.74 13.16
Hosein 2020 0.09 0.16 0.02 6.80 13.25
Kulshrestha 2021 0.09 0.04 0.15 6.82 13.30
Benedixet 2021 0.22 0.56 0.12 5.60 11.09
Lekarczyk 2020 0.40 0.87 0.07 4.93 9.61
Tjeerdsma 2022 0.31 0.27 0.09 4.29 8.37

Overal 0.21 0.53 0.11

Model: random-effects model 1.5 1.0 0.5 0 0.5 1.0

Heterogeneity: Tau-squared = 0.15, H-squared = 32.59, I-squared = 0.97
Test of overall effect size: t = 1.54, df = 8, p-value = 0.16

Effect size of each study Confidence interval of effect size

C Estimated overall effect size Overall effect size value
No-effect value Estimated overall confidence interval

ID Cohen s d Lower Upper Weight Weight (%) 0.182673

O'connor 2020 0.05 0.17 0.26 11.90 20.06

Soliman 2019 0.44 0.21 0.67 11.67 19.68
Gehrig 2012 0.11 0.63 0.85 4.67 7.88
Benedixet 2021 0.63 0.28 0.98 9.70 16.36
Lekarczyk 2020 0.17 0.30 0.63 7.82 13.18
Gerull 2020 0.20 0.30 0.11 13.54 22.83

Overall 0.18 0.15 0.52

1.0 0.5 0 0.5

Model: random-effects model
Heterogeneity: Tau-squared = 0.07, H-squared = 5.77, I-squared = 0.83
Test of overall effect size: t = 1.41, df = 5, p-value = 0.22

Fig. 2. Forest plots. (A) Meta-analysis of overall postoperative complication rates [3–5,7,8,22]. (B) Meta-analysis of length of stay
[4,5,7–10,22,27,28]. (C) Meta-analysis of mean operation time [4,5,7,9,10,27].

6 https://doi.org/10.7602/jmis.2023.26.3.1
 Robotic-assisted versus laparoscopic paraesophageal hernia repair

Primary studies Primary studies

95% pseudo confidence intervals 95% pseudo confidence intervals
Estimated overall effect size Estimated overall effect size
(observed studies) (observed studies)
A B
0 0
Gerull 2020 Kulshrestha 2021
Hosein 2020
0.2
0.1
O'connor 2020
Standard error

Standard error
0.4 Soliman 2019

Benedixet 2021

0.6 0.2
Lekarczyk 2020

0.8 Tjeerdsma 2022

0.3
1.0
Gehrig 2012

1.2 0.4
2 0 2 4 1.0 0.5 0 0.5 1.0

Primary studies
95% pseudo confidence intervals
Estimated overall effect size
(observed studies)
C
0
Gerull

0.1 O'connor
Soliman
Standard error

Benedixet 2021

0.2
Lekarczyk 2020

0.3
Fig. 3. Funnel plots. (A) Meta-analysis of overall postoperative
Gehrig complication rates [3–5,7,8,22]. (B) Meta-analysis of length of
0.4 stay [4,5,7–10,22,27,28]. (C) Meta-analysis of mean operation
1.0 0.5 0 0.5 1.0 time [4,5,7,9,10,27].

especially for small-size studies. The surgeons who performed
the operations reported by Soliman et al. [4] had little or no
experience with robotic surgery. In addition, mesh placement,
which might affect the operation time, is mentioned in only two
studies [5,8]. Another important factor is that the article reported
by Gerull et al. [10] is a retrospective database study, whereas
all the other articles included are single-center studies. This fact
might have affected the heterogeneity which was significant,
up to 82.7%, as well as the funnel plot (Fig. 3C). In order to deal
with the heterogeneity, sensitivity analysis was performed and
the study published by Gerull et al. [10] was excluded, as the
study with the highest weight. Meta-analysis was performed
again showing less heterogeneity (I2, 58%), but still no statisti-
cally important difference (t = 0.3, df = 5; 95% CI, –0.02 to 0.62;
p = 0.06) (Fig. 4A, B).
In general, the use of mesh is a very important element for
hiatal hernia reconstruction, but unfortunately, few studies pro-
vide evidence about this factor. Soliman et al. [4] reported that
mesh was used in only four of a total of 293 patients. O’Connor
et al. [9] reported that mesh placement was performed more
frequently in the laparoscopic group with a p < 0.001, whereas
Tjeerdsma et al. [8] found no difference in the use of mesh
between the two groups, although in a smaller sample. More
studies regarding the use of mesh and its correlation with the
operative time, the complications, and the recurrence rates are
needed.
Only three studies provided evidence in regard to estimated
blood loss. Gehrig et al. [7] stated that there is no statistically
important difference between the laparoscopic and robotic
groups.
Not enough data were provided concerning the recurrence
rates in order to perform the meta-analysis. Only O’Connor et

https://doi.org/10.7602/jmis.2023.26.3.1 7
Last named et al.

A Effect size of each study Confidence interval of effect size

Estimated overall effect size Overall effect size value
Estimated overall confidence interval
Forest plot
0.298881
ID Cohen's d Lower Upper p-value Weight Weight (%)

O'connor 0.08 0.17 0.26 0.00 20.01 20.88

Soliman 2019 0.44 0.21 0.67 0.00 19.37 27.63
Gehrig 2012 0.11 0.63 0.05 0.70 5.56 7.93
Bnedix 2021 0.63 0.30 0.90 0.00 14.49 20.60
Lekarczyk 2022 0.17 0.30 0.63 0.40 10.65 18.20

Overall 0.30 0.02 0.62 0.06

Model: random-effects model 1.0 0.5 0 0.5

B Funnel plot
0 Primary studies
95% pseudo confidence intervals
Estimated overall effect size
0.1 (observed studies)
Standard error

0.2

0.3

0.4
0.5 0 0.5 1.0 1.5 Fig. 4. Meta-analysis of mean operation time after conducting
Cohen s d a sensitivity analysis. (A) Forest plot. (B) Funnel plot.

al. [9] stated that the robotic group had a lower radiologic re-
currence rate (13.3% compared to 32.8% in the laparoscopic
group with a p -value of 0.008; OR, 0.31 [95% CI, 0.17–0.57]) in a
1-year follow-up (Table 2).
Unfortunately, all of the studies included in the meta-analysis
are retrospective and none of them is randomized. Due to the
considerable heterogeneity, the results of the meta-analysis are
not reliable. Further studies and especially randomized control
studies are needed in order to reach reliable conclusions.
DISCUSSION
Robotic-assisted surgery is becoming more and more popu-
lar among surgeons since it overcomes the technical difficul-
ties of conventional laparoscopy. Its safety and efficacy have
been proven even for oncologic procedures, while its cost has
been justified for procedures with limited anatomic space, such
as radical prostatectomy, low anterior resection, and bariatric
procedures. Especially for the paraesophageal hernia repair,
which is a technically challenging procedure, demanding high
mediastinal dissection, complete removal of the hernia sac, a
low-tension hiatal reconstruction with sutures, with or without
mesh placement, robotic technology seems a very useful tool
to overcome these difficulties, restricting the need to conversion
to open surgery [11,12]. However, according to the presented
meta-analysis, the short-term outcomes with regard to opera-
tion time, LOS, and postoperative complications are equivalent,
whereas there is not enough data in the literature concerning
the long-term outcomes and specifically the recurrence rates.
Robotic approach might be very useful for the repair of re-
current or complex hiatal hernias [9], which are accompanied
by higher morbidity and mortality as well as less satisfactory
symptomatic outcome [13]. Seetharamaiah et al. [14] reported
a series of 19 robotic repairs of giant paraesophageal hernias,
with only two surgery-related complications, one conversion
to open approach and no recurrence in a mean follow-up pe-
riod of 15.6 months. Taking into consideration that the majority
of complications are pulmonary events and pneumonia, the

8 https://doi.org/10.7602/jmis.2023.26.3.1
 Robotic-assisted versus laparoscopic paraesophageal hernia repair
robotic approach enables better visualization and ergonomics
during the dissection of the hernia sac from the delicate pleura
[9]. In addition, it provides high-quality hiatal reconstruction and
suturing even in the reoperative field, which is characterized by
changed anatomical planes and demands extensive adhesioly-
sis. As a result, the surgeons, being aware of the capabilities of
the robot, feel more confident, a fact which explains the lower
conversion to open procedure rates for redo hiatal hernias [13].
The conversion rate for redo hiatal hernias with the laparo-
scopic approach might be as high as 11% [15]. Gerull et al. [10]
also reported a higher percentage of redo hernias in the robotic
group, as well as a lower percentage of esophageal lengthening
procedure, such as Collis gastroplasty and wedge fundectomy.
Mertens et al. [6] presented a large series of both primary and
redo robotic-assisted hiatal hernia repair with major complica-
tion rate up to 5.2% and 2.6% respectively, while the incidence
of complications of any severity were 17.1% and 10.6%, indicat-
ing that the low number of complications in the redo group was
not significantly different from the primary procedure group. The
presence of strong adhesions and the strangulation of a signifi-
cant portion of abdominal viscera consist the two main reasons
for conversion in the robotic group [6]. Sowards et al. [16] men-
tioned longer operative times, increased hospital LOS, and the
use of mesh in the recurrent group compared to the primary
group, with no significant difference in intraoperative complica-
tions, estimated blood loss, or postoperative dysphagia, while
no conversion was noticed. On the other hand, a single-center
retrospective study by Tolboom et al. [13] reported a significant
reduction in conversion rates and in hospitalization time in the
robotic-assisted redo group, whereas the most common com-
plication was the perforation of the esophagus or the stomach.
Nevertheless, previous laparoscopic antireflux surgery does not
suggest an indication for open approach in case of recurrence;
if a robotic platform is available in combination with an experi-
enced surgical team, a robotic approach is recommended.
Experience from robotic redo hiatal hernia repair after pri-
mary robotic procedure is provided by Arcerito et al. [17], who
mentioned the increased possibility of conversion to open
approach due to the severe scar tissue lying between hiatal
crura and fundoplication, which developed more likely from the
placement of an absorbable mesh. However, no mesh-related
complications are mentioned during a two-and-a-half-year time
period [17], thanks to the absorbable property, even in longer
follow-up periods [18].
Regarding the learning curve, it is believed that the robotic
approach has a shorter learning curve compared to laparos-
https://doi.org/10.7602/jmis.2023.26.3.1
copy for advanced surgical procedures, while a significant case
volume and dedicated operation room staff can significantly re-
duce the operation time [19]. Galvani et al. [20], in a large cohort
of 61 robotic procedures all performed by one surgeon, claimed
a learning curve of 36 cases, comparable to conventional lapa-
roscopy. Sarkaria et al. [12] in a series of 24 patients, noticed
that the operation time was decreased by 98 minutes between
the second and the first half of the series. Washington et al.
[21] also reported shorter operative time between the early and
the late robotic experience, 184 and 142 minutes respectively,
as well as a significant decrease in conversion rates, after only
one year of thirteen robotic procedures.
Another topic of interest is the application of the robotic
platform in the emergency setting in cases of strangulation of
hernia contents. According to a study published by Hosein et
al. [22], minimally invasive approaches predominate even in the
urgent setting, with better postoperative outcomes, with the
open approach being selected only for extremely ill patients.
The robotic approach was superior to the open one for mild to
moderate ill patients, but not superior to the laparoscopic ap-
proach. In another study by Vasudevan et al. [19], 40% of the
robotic procedures were performed on patients presenting with
acute symptoms and neither higher operative time nor conver-
sions were observed in comparison to elective cases. Arcerito
et al. [17] also suggested the robotic approach for the treatment
of acutely presented hiatal hernias even on admission day.
Equivalent outcomes were noticed even for complete upside-
down stomach hiatal hernias [23]. Because of the higher cost,
the robotic approach is reserved for giant or revisional hiatal
hernias in some centers [22].
Regarding the recurrence rates, there is not enough evidence
in the literature concerning the long-term outcomes. Mertens
et al. [6] reported two cases of early symptomatic recurrence
requiring redo surgery during the 30-day postoperative period.
Draaisma et al. [24] reported a low midterm recurrence rate
after 1 year of follow-up. Brenkman et al. [25], in a cohort of
40 patients and during an 11-month follow-up period, reported
only one symptomatic recurrence (2.5%). He attributed this
result to the application of the robotic platform and the Toupet-
fundoplication, which attached to the crus, provides further
support to the hiatal repair, while no mesh was placed. Galvani
et al. [20] in a cohort of 61 patients, where mesh was used in all
cases, and during a median follow-up period of 24 months, re-
ported a radiologic recurrence rate up to 42%, pointing out that
the majority of the patients were asymptomatic and indicating
than the durability of the repair decreases over time. Arcerito
9
Last named et al.

et al. [17] also provided promising evidence regarding the long- the conventional laparoscopic approach, which remains the
term recurrence rate during two-and-a-half years of follow-up. most cost-effective approach. Robotic paraesophageal hernia
In one of the largest studies with paraesophageal hiatal hernia repair is safe and feasible, but still not superior to laparoscopy,
repair by Gerull et al. [11], a radiographic recurrence rate of only unless in cases with recurrent complex hernias. It is obvious
9% during 5 years of observation is reported, in combination that more comparative and mainly randomized control studies
with clinically significant quality of life benefits. The presentation with subgroup analysis need to be performed in order to reach
of recurrence may not solely depend on the surgical technique more accurate conclusions and find out which patients would
but also on the presence of ultrastructural abnormalities in the benefit most. A long-term follow-up of the patients is essential
muscular tissue of the crura in patients with hiatal hernia. These because there is a lack of evidence in the literature concerning
patients often exhibit a high incidence of severe muscular le- the recurrence rates of each approach.
sions, which are not observed in individuals with a normal
gastroesophageal junction [26]. This evidence supports the NOTES
application of mesh in order to strengthen the hiatal repair and
lower the recurrence rates.
Robotic procedures in general are associated with higher Ethical statements
costs. Interestingly, Gerull et al. [11] reported that the operation This systematic review and meta-analysis were conducted in
equipment costs were similar between robotic and traditional accordance with ethical principles and guidelines. As this study
laparoscopic paraesophageal hernia repair, with a mean dif- is a retrospective literature review, institutional ethics committee
ference of only $89. Lekarczyk et al. [27] found similar hospital approval was not required.
profits for the robotic group despite higher supply costs and
charges. However, Kulshrestha et al. [28], in a study with more Authors’ contributions
participants, reported that both open and robotic-assisted Conceptualization, Investigation, Methodology, Software: SE
procedures had significantly higher median index hospitaliza- Data curation, Validation: GI
tion costs compared to laparoscopic ones. The most common Formal analysis: KA
reasons that increased the cost were upper endoscopy and re- Funding acquisition, Supervision, Resources: MK
operation, followed by emergent priority, increased comorbidity Project administration: KA
index, and LOS. Hosein et al. [22] also demonstrated that the Visualization: PP
laparoscopic approach was the least expensive. However, the Writing–original draft: SE
increased experience of the surgeons with the robotic platform, Writing–review & editing: PP
which will lead to fewer complications, LOS, and postoperative All authors read and approved the final manuscript.
exams, as well as the fact that the cost of the robotic equip-
ment will go down over time, might diminish this difference in Conflict of interest
the future. All authors have no conflicts of interest to declare.
The robotic platform has been used successfully for the re-
pair of other diaphragmatic hernias, such as Morgagni [29,30], Funding/support
Bochdalek [31], and even postesophagectomy hiatal hernias None.
[32], indicating its potential in technically demanding procedures.
Over the last decades, esophageal surgery has evolved from Data availability
open approaches including both laparotomy and thoracotomy The data presented in this study are available on request from
to minimally invasive procedures. The robotic-assisted hiatal the corresponding author.
hernia repair is superior to the traditional open approach in
terms of overall complication rate, mortality [20], postoperative ORCID
pain, and hospital LOS. However, its superiority over conserva- Symeonidou Elissavet, https://orcid.org/0000-0001-7297-841X
tive laparoscopy has not been proven yet. Gkoutziotis Ioannis,
The present meta-analysis did not demonstrate any advan- Petras Panagiotis,
tage of the robotic-assisted paraesophageal hernia repair over Mpallas Konstantinos,

10 https://doi.org/10.7602/jmis.2023.26.3.1
 Robotic-assisted versus laparoscopic paraesophageal hernia repair
Kamparoudis Apostolos
REFERENCES
1. McHugh ML. Interrater reliability: the kappa statistic. Bio-
chem Med (Zagreb) 2012;22:276-282.
2. IntHout J, Ioannidis JP, Borm GF. The Hartung-Knapp-
Sidik-Jonkman method for random effects meta-analysis
is straightforward and considerably outperforms the stan-
dard DerSimonian-Laird method. BMC Med Res Methodol
2014;14:25.
3. Ward MA, Hasan SS, Sanchez CE, Whitfield EP, Ogola
GO, Leeds SG. Complications following robotic hiatal her-
nia repair are higher compared to laparoscopy. J Gastroin-
test Surg 2021;25:3049-3055.
4. Soliman BG, Nguyen DT, Chan EY, et al. Robot-assisted
hiatal hernia repair demonstrates favorable short-term out-
comes compared to laparoscopic hiatal hernia repair. Surg
Endosc 2020;34:2495-2502.
5. Benedix F, Adolf D, Peglow S, Gstettenbauer LM, Croner
R. Short-term outcome after robot-assisted hiatal hernia
and anti-reflux surgery-is there a benefit for the patient?
Langenbecks Arch Surg 2021;406:1387-1395.
6. Mertens AC, Tolboom RC, Zavrtanik H, Draaisma WA,
Broeders IA. Morbidity and mortality in complex robot-
assisted hiatal hernia surgery: 7-year experience in a high-
volume center. Surg Endosc 2019;33:2152-2161.
7. Gehrig T, Mehrabi A, Fischer L, et al. Robotic-assisted
paraesophageal hernia repair: a case-control study. Lan-
genbecks Arch Surg 2013;398:691-696.
8. Tjeerdsma M, Quinn KR, Helmer SD, Vincent KB. Com-
paring outcomes of robotic-assisted versus conventional
laparoscopic hiatal hernia repair. Kans J Med 2022;15:365-
368.
9. O’Connor SC, Mallard M, Desai SS, et al. Robotic versus
laparoscopic approach to hiatal hernia repair: results after
7 years of robotic experience. Am Surg 2020;86:1083-
1087.
10. Gerull WD, Cho D, Arefanian S, Kushner BS, Awad MM.
Favorable peri-operative outcomes observed in para-
esophageal hernia repair with robotic approach. Surg En-
dosc 2021;35:3085-3089.
11. Gerull WD, Cho D, Kuo I, Arefanian S, Kushner BS, Awad
MM. Robotic approach to paraesophageal hernia repair
results in low long-term recurrence rate and beneficial
patient-centered outcomes. J Am Coll Surg 2020;231:520-
https://doi.org/10.7602/jmis.2023.26.3.1
526.
12. Sarkaria IS, Latif MJ, Bianco VJ, et al. Early operative out-
comes and learning curve of robotic assisted giant para-
esophageal hernia repair. Int J Med Robot 2017;13:e1730.
13. Tolboom RC, Draaisma WA, Broeders IA. Evaluation of
conventional laparoscopic versus robot-assisted laparo-
scopic redo hiatal hernia and antireflux surgery: a cohort
study. J Robot Surg 2016;10:33-39.
14. Seetharamaiah R, Romero RJ, Kosanovic R, et al. Robotic
repair of giant paraesophageal hernias. JSLS 2013;17:570-
577.
15. Kao AM, Otero J, Schlosser KA, et al. One more time:
redo paraesophageal hernia repair results in safe, du-
rable outcomes compared with primary repairs. Am Surg
2018;84:1138-1145.
16. Sowards KJ, Holton NF, Elliott EG, et al. Safety of robotic
assisted laparoscopic recurrent paraesophageal hernia
repair: insights from a large single institution experience.
Surg Endosc 2020;34:2560-2566.
17. Arcerito M, Perez MG, Kaur H, Annoreno KM, Moon JT.
Robotic fundoplication for large paraesophageal hiatal her-
nias. JSLS 2020;24:e2019.00054.
18. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic
prosthesis to prevent recurrence after laparoscopic para-
esophageal hernia repair: long-term follow-up from a
multicenter, prospective, randomized trial. J Am Coll Surg
2011;213:461-468.
19. Vasudevan V, Reusche R, Nelson E, Kaza S. Robotic
paraesophageal hernia repair: a single-center experience
and systematic review. J Robot Surg 2018;12:81-86.
20. Galvani CA, Loebl H, Osuchukwu O, Samamé J, Apel ME,
Ghaderi I. Robotic-assisted paraesophageal hernia repair:
initial experience at a single institution. J Laparoendosc
Adv Surg Tech A 2016;26:290-295.
21. Washington K, Watkins JR, Jeyarajah DR. The first year is
the hardest: a comparison of early versus late experience
after the introduction of robotic hiatal hernia repair. J Robot
Surg 2020;14:205-210.
22. Hosein S, Carlson T, Flores L, Armijo PR, Oleynikov D.
Minimally invasive approach to hiatal hernia repair is supe-
rior to open, even in the emergent setting: a large national
database analysis. Surg Endosc 2021;35:423-428.
23. Wilhelm A, Nocera F, Schneider R, et al. Robot-assisted
vs. laparoscopic repair of complete upside-down stomach
hiatal hernia (the RATHER-study): a prospective compara-
tive single center study. Surg Endosc 2022;36:480-488.
11
Last named et al.
24. Draaisma WA, Gooszen HG, Consten EC, Broeders IA.
Mid-term results of robot-assisted laparoscopic repair of
large hiatal hernia: a symptomatic and radiological pro-
spective cohort study. Surg Technol Int 2008;17:165-170.
25. Brenkman HJ, Parry K, van Hillegersberg R, Ruurda JP.
Robot-assisted laparoscopic hiatal hernia repair: promis-
ing anatomical and functional results. J Laparoendosc Adv
Surg Tech A 2016;26:465-469.
26. Fei L, del Genio G, Rossetti G, et al. Hiatal hernia recur-
rence: surgical complication or disease?: electron micro-
scope findings of the diaphragmatic pillars. J Gastrointest
Surg 2009;13:459-464.
27. Lekarczyk A, Sinha H, Dvir D, Goyert J, Airhart A, Reddy
RM. Similar hospital profits with robotic-assisted para-
esophageal hiatal hernia repair, despite higher or supply
costs. Surg Endosc 2023;37:3952-3955.
28. Kulshrestha S, Janjua HM, Bunn C, et al. State-level ex-
12
amination of clinical outcomes and costs for robotic and
laparoscopic approach to diaphragmatic hernia repair. J
Am Coll Surg 2021;233:9-19.
29. Machado MA, Epstein MG, Lobo Filho MM, Mattos BH,
Makdissi FF. Robotic repair of Morgagni hernia in adult pa-
tient. Arq Gastroenterol 2022;59:549-550.
30. Gergen AK, Frankel JH, Weyant MJ, Pratap A. A novel
technique of robotic preperitoneal approach for Morgagni
hernia repair. Asian J Endosc Surg 2021;14:648-652.
31. Hunter LM, Mozer AB, Anciano CJ, Oliver AL, Iannettoni
MD, Speicher JE. Robotic-assisted thoracoscopic repair of
right-sided bochdalek hernia in adults: a two-case series.
Innovations (Phila) 2019;14:69-74.
32. Bigolin AV, Fonseca MK, Grossi J, Iaroseski J, Cavazzola
LT. Robotic repair of post-oesophagectomy hiatal hernia.
Ann R Coll Surg Engl 2022;104:e171-e173.
https://doi.org/10.7602/jmis.2023.26.3.1