Gastrointestinal surgery entered a new era with the introduction of laparoscopic surgery in the late 1980s and robotic surgery in the early 1990s [11, 12]. These minimally invasive techniques have revolutionized operative medicine in the majority of surgical specialties. Compared to open surgery, conventional laparoscopy (CL) offer multiple advantages including decreased postoperative pain and post operative morbidity, improved cosmesis, faster recovery, and decreased length of hospital stay [13]. Despite these advantages, CL carries with it multiple disadvantages and limitations such as reduced surgical dexterity, poor surgical ergonomics, translation of natural tremors, 2-dimensional visualization, and a steep learning curve to master most complex gastrointestinal operations [14–16]. These limitations along with advancement in computer technology and robotics led to the birth of surgical robotic systems. This novel technology started in 1985 with the Puma 560 platform that was used in the field of neurosurgery. Over the next decade, multiple other platforms were introduced into the market to assist in different specialties such as orthopedics and urology. The automated endoscopic system of optimal positioning (AESOP) was the first robotic platform used in abdominal surgery in the 1990s. Over the next few years, this technology underwent multiple phases of refinement to give rise to da Vinci surgical system (Intuitive Surgical, Inc., Sunnyvale, CA). This new platform was FDA approved in July of 2000 for use in general surgery procedures. While maintaining most of the advantages offered by CL, surgical robots were designed to provide promising solutions for most of the limitations and drawbacks encountered with CL [15].

Currently, the most widely used robotic system in gastrointestinal surgery is the da Vinci surgical system. There are several other platforms either in development or soon to enter the market, including systems developed by Titan Medical (Toronto, Ontario, Canada), Verb Surgical (Mountain View, CA), Medtronic (Minneapolis, MN), and Transenterix (Morrisville, NC).

The da Vinci system consists of a surgeon console, patient side-cart, and a vision system. The console consists of a stereoscopic viewer, controllers, and pedals that allow the surgeon to be comfortably seated and engrossed in the surgical field in order to minimize fatigue and distraction. The side cart consists of three or four robot arms that translate the surgeon’s movements at the console. Multiple endowrist instruments that carry different functions have been designed. These instruments are designed with seven degrees of motion, a range of motion similar to human wrist. The vision system consists of a high definition 3D endoscope and a large vision cart that provide enhanced visualization for the operating surgeon, as well as the rest of the OR team. In addition, the surgeon’s movements are digitalized which allow exclusion of surgical tremors and improve motion scaling up to five times, which may result in increased operative precision [17–19].

Historically, PEH repair was done through an open transthoracic or transabdominal approach. However, with the development of laparoscopic techniques, large acceptance and adoption of minimally invasive techniques have been seen by most surgeons. This enthusiasm was further boosted by multiple early reports demonstrating the ability to perform large PEH repairs using laparoscopic techniques safely and with good symptomatic results [9, 10]. Although CL offered its inherent set of advantages that is seen in the perioperative course, most initial series reported higher recurrence rates. The recurrence rate ranged from 16 to 57% with the laparoscopic approach compared to 2 to 15% with the open approach. Despite this higher recurrence rates, multiple studies showed that this recurrence is often a radiographic finding that lacks any clinical implications. In addition, the majority of these patients with a documented radiographic recurrence had excellent clinical outcomes and improved quality of life with very few that required reoperation [20, 21]. The introduction of robotic surgical system into foregut surgery was believed to improve upon CL and potentially yield better operative outcomes.

The first robotic assisted laparoscopic (RAL) Nissan fundoplication was done by Cadiere and colleagues (1999, France). Cadiere went on to conduct a prospective randomized trial comparing the outcome of robotic versus laparoscopic Nissan fundoplication in 21 patients. Both approaches had similar outcomes although operative time was significantly longer in the robotic group (72 vs. 52 min, p < 0.01) [22]. Multiple other studies were then carried out comparing robotics to CL. These studies demonstrated an average of a 30 min longer operative time and a total of 2000 US dollar higher cost with the robotic platform [19]. On the other hand, robotic surgery was proven to be a safe alternative with comparable clinical outcomes to CL. Despite the thoughts that robotic surgery would yield better patient outcomes in antireflux and hiatal hernia surgery, this was not seen in clinical studies when it was compared to CL [23–25]. Of note, most of the studies were performed on patients with symptomatic GERD and/or small type I hiatal hernia. Perhaps, if CL was compared to robotic platforms with large and more complex PEH that require more dissection and precision of movements in the narrow hiatus, then significant clinical advantages may be seen. The role of robotics continues to represent an area ripe for research and prospective trials.

The operative management for GERD and treatment of PEHs increased dramatically in the past decade. This increase occurred with the introduction and advancement in the minimally invasive techniques which was demonstrated to be safe, effective, and with a low risk of operative morbidity and mortality [26]. This led to more patients with failed primary surgical repair being encountered in the clinical setting. Most studies report recurrence rates of around 28% after primary repair. The pathogenesis of PEH recurrence is multi-factorial and includes patient characteristics, physiologic factors such as repetitive movement of the diaphragm, and technical factors. Patient related factors include obesity, presence of atypical symptoms, poor response to medications, pulmonary disease, smoking, prior abdominal surgeries, and size of the PEH [27]. Technical factors that have been associated with increased rates of recurrence include inadequate dissection of hiatus, failure to recognize short esophagus or inadequate dissection of the esophagus, false identification of GE junction, sub-optimally constructed wrap, and vagal nerve injury. Upon reoperation, transdiaphragmatic migration of wrap and disruption of wrap were the two most common causes for failure [28–30]. Despite the relatively high recurrence rate of laparoscopic PEH, only a minority of patients are symptomatic and require reoperation. The most common indication for reoperation includes reflux, dysphasia, and bloating along with a documented radiographic abnormality [31].

Patients with failed PEH repair embody a complicated clinical picture and a technical challenge for surgeons. Reoperations are often more complex due to dense adhesions, scarred surgical planes, and altered anatomy [32]. Not surprisingly, these challenges are greater if the primary repair was done via an open approach. Compared to primary repair, redo surgery has higher mortality, higher intraoperative and postoperative complication rate, and lower satisfactory symptomatic outcomes [27, 31–37]. Further, clinical outcomes become less satisfactory if more than one reoperation is needed [27, 34–37]. The satisfaction rate drops to 42% with patients requiring three or more operations [34]. Therefore, studies suggest that patients have best outcomes with their primary surgical repair followed by the first reoperation.

Patients being considered for reoperation should have a thorough evaluation. One must obtain a detailed history regarding their initial preoperative symptoms, response to the operation, and whether these symptoms persisted after the primary repair or new symptoms arise. A complete workup for esophageal and gastric disorders should be undertaken, with comprehensive testing with radiographs, barium esophagogram, pH study, endoscopy, esophageal manometry, and gastric emptying studies [27, 35–37].

These tests may reveal an undiagnosed underlying problem such as abnormal esophageal motility, abnormal stomach emptying, and/or a short esophagus. With this preoperative information, surgeons can often tailor their operative plans to the individual patients. As an example, patients with dysphasia might need a partial fundoplication during their reoperation, those having true shortened esophagus might benefit from an esophageal lengthening procedure and/or more aggressive mediastinal dissection, and patients that are obese or have major esophageal dysmotility might benefit from roux-en-y (RNY) gastrojejunostomy or esophagojejunostomy . In carefully selected patients, an even more aggressive operation such as esophagectomy may be required [27, 31–37].

Traditionally, patients being evaluated for redo PEH repair are referred to thoracic and or gastrointestinal surgeons and a majority of the redo operations are done via an open approach. Around 66% of patients are done via transabdominal approach and 25% are done via transthoracic approach. However, up to one third of patients are currently being done via laparoscopy due to the increased experience and skills in minimally invasive techniques.

Outcomes after the first reoperation for a failed antireflux surgery are satisfactory with long term satisfaction rates of about 80% as compared to 95% seen after a primary repair [33]. Intraoperative and postoperative complication rates are far more common after redo surgery (21.4% and 15.6%, respectively) [31]. Postoperative complications and mortality are higher with an open approach. On the other hand, intraoperative complications were much higher in the laparoscopic group and rate for conversion to open surgery was around 8.7% [31]. Reasons for conversion include dense adhesions, intraoperative bleeding, and poor visualization. In addition, current literature demonstrates that failure of laparoscopic redo operation is as high as 11% and these patients required additional revisional operations [32, 33, 35].

These factors along with the known advantages of the robotic surgical system have led many investigators to revisit the role of robotic surgery in redo antireflux and hiatal hernia surgery. Currently there is paucity of studies looking at the role of robotic surgical system in redo antireflux and hiatal hernia repair. Tolboom et al., in a single cohort study, included 75 patients who underwent either CL or RAL redo surgery. He found that median hospital stay was reduced by 1 day in the robotic group. In addition there was less conversion to open surgery in the RAL group. There was no difference in mortality rates, complications, and outcomes between the two groups [38]. There is some data that can be gleaned from robotic revisional bariatric surgery that may point to a role for robotics in re-do antireflux surgery and the basis for additional future trials. Although small, series of robotic revisional bariatric surgery demonstrate decreased conversion rates to open surgery, complication rates, hospital length of stay, as well as major complication rates approaching that of primary bariatric surgical options [39–42].

The set up for RAL primary and/or revisional PEH repair is similar to that of other foregut operations. The set-up used by the authors is similar, with minor modifications, to techniques described by others. Patients are positioned in steep reverse Trendelenburg with care taken to pad all pressure points. Using either the SI or XI system, four robotic arms are utilized with or without an accessory port. Port configuration is noted in Fig. 18.2. A parallel side dock technique is utilized for positioning of the patient side cart (Figs. 18.3 and 18.4).