Robot-Assisted Technology May Be Viable Option to Repair Complete Upside-Down Stomach Hiatal Hernia

hernia repair
hernia repair
The prospective, comparative RATHER study was conducted to assess intraoperative and postoperative outcomes following repair of complete upside-down hiatal hernia.

The clinical outcome of robot-assisted surgery was found to be at least equal to that obtained by standard laparoscopic surgery for repair of complete upside-down stomach (cUDS) hiatal hernia, according to the results of a study published in Surgical Endoscopy.

The prospective, comparative RATHER study enrolled patients with cUDS herniation requiring elective surgery at a university center in Switzerland between July 2015 and June 2019. The primary endpoints were intraoperative and postoperative complications and mortality within 30 days after surgery.

The study included 55 patients; 36 patients (median age, 71 years; 64% women) were treated with robot-assisted (Rob-G) surgery, and 19 patients (median age, 76 years; 74% women) were treated with the standard laparoscopic (Lap-G) technique. Baseline characteristics of the patients were similar among the 2 groups.

Participants were contacted via telephone to assess symptoms associated with recurrence during a follow-up of 8 to 53 months. The Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire was used to evaluate patients’ quality of life.

The median operation time was significantly longer in the Rob-G group compared with the Lap-G group (232 min, interquartile range [IQR], 145-420 vs 163 min, IQR, 112-280, respectively; P < .001). Intraoperative complications were observed in 5/36 (12.5%) patients in the Rob-G group and in 5/19 (26%) patients in the Lap-G group (P = .28). No operation required conversion in either patient group. The median postoperative hospital stay was 8.5 (IQR, 4-21) days in the Rob-G group compared with 8 (IQR, 4-15) days in the Lap-G group (P = .96).

Minor postoperative complications were observed in 13/36 (36%) patients undergoing the Rob-G procedure and in 4/19 (21%) undergoing the Lap-G procedure (P = .36). No mortality or major complications occurred in either group. No patient required revision surgery, and 2 asymptomatic recurrences were observed in the Rob-G group. All patients expressed satisfaction with their treatment outcome, according to their GERD-HRQL scores.

“While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery,” stated the study authors.

The investigators noted that their study population was relatively small, and the follow-up of asymptomatic patients did not include regular endoscopy or imaging. Also, quality of life was not assessed preoperatively; therefore, baseline comparison of the subjective outcome was not possible.

“Most importantly, our data indicate that intra- and postoperative outcomes of a surgical procedure as technically demanding as cUDS hiatal hernia repair by robot-assisted technology are not inferior to those obtained by using standard laparoscopic technology,” commented the researchers.

“Considering the less traumatic tissue dissection, the additional precision with enhanced tri-dimensional visualization, the augmented accuracy associated with superior exposure of anatomical landmarks, and the higher feasibility due to increased freedom of motion, our results support a more extensive use of robot-assisted technology in cUDS hiatal hernia repair,” the study authors concluded.


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 comparative single center study. Surg Endosc. Published online February 1, 2021. doi:10.1007/s00464-021-08307-2