Robotic Surgical Repair of a Parahiatal Hernia: A Case Report

Introduction

Hiatal hernias are characterized by the herniation of abdominal contents, most commonly the stomach, through the esophageal hiatus of the diaphragm into the thoracic cavity [1]. They are classified into 4 distinct types based on the position of the gastroesophageal (GE) junction and the degree of herniation. Type I, the sliding hernia, constitutes approximately 95% of cases and features intermittent displacement of the GE junction above the diaphragm; it is frequently associated with gastroesophageal reflux disease. Types II, III, and IV are paraesophageal hernias (PEHs) [2]. Type II involves herniation of the gastric fundus alongside a normally positioned GEJ. Type III, a mixed hernia, is where both the GE junction and stomach herniate superiorly [3]. Type IV includes herniation of other abdominal organs, such as the colon and spleen, in addition to the stomach [4]. PEHs (types II–IV) are less common but carry a significant risk for mechanical complications, such as obstruction, volvulus, or strangulation. Parahiatal hernias (PHHs) are extremely rare, with fewer than 30 documented cases in the literature as of 2020 [5]. The estimated incidence of PHH is between 0.2% and 0.35%, with most cases documented as case reports on incidental findings [6]. PHHs result from a defect distinct from the esophageal hiatus and are frequently misidentified as PEHs due to their proximity to the hiatus [6,7]. This report presents a case of PHH managed successfully with robotic-assisted laparoscopic repair, aiming to contribute to the evolving understanding of this condition and its surgical management.

Case Report

SURGICAL TECHNIQUE:

Following the standard induction of general anesthesia, a 5-mm supraumbilical incision was made for the entry device (Visiport), and 3 additional robotic ports were placed bilaterally in the upper quadrants. A subxiphoid incision was created for liver retraction. Next, the patient was placed in the reverse Trendelenburg position. The da Vinci robotic system was docked, and the procedure commenced.

Upon entry into the peritoneal cavity, the stomach was noted to be twisted, consistent with gastric volvulus (Figure 5). Extensive adhesiolysis was performed using an orbital vessel sealer and energy source, allowing the stomach to return to its anatomical position. The gastrohepatic ligament was divided to facilitate further dissection of the hernia sac. Examination revealed that the defect was lateral to the hiatus, confirming PHH rather than PEH.

A careful robotic dissection was performed to separate the hernia sac from the surrounding peritoneal attachments. The visualization provided by the robotic system allowed for precise tissue handling and identification of critical anatomical structures. The dissection was conducted using monopolar scissors and bipolar energy devices to minimize collateral tissue damage. The robotic EndoWrist instruments facilitated fine control for meticulous suturing.

The diaphragmatic defect was meticulously closed with a running 0 non-absorbable polyethylene terephthalate (Ethibond) suture reinforced with interrupted 0 Ethibond sutures, ensuring no undue tension. A double-layer closure technique was used to reinforce the repair, reducing the risk of recurrence. A biologic mesh was considered but ultimately deemed unnecessary by the surgeon and a second consulting surgeon, given the absence of excessive tension. The hiatus remained within normal limits, negating the need for fundoplication. Copious saline irrigation was performed, and ports were removed under direct visualization. Incisions were approximated with 4-0 monocryl sutures, and Dermabond tissue adhesive was applied.

Mesh was omitted during the repair for several intraoperative and evidence-based reasons. Permanent mesh is often used to reinforce hernia repairs and reduce the risk of recurrence, in the present case, the defect was located near the GE junction. Overlaying this area with permanent mesh would have required wrapping the GE junction, which has been associated with a risk of mesh erosion into the esophagus, particularly in the setting of chronic reflux and inflammation [8]. While this patient did not have reflux-related pathology, the surgical team opted to avoid this risk. Studies have documented severe complications, including mesh erosion and stricture, when synthetic mesh is placed near the GE junction [8]. The alternative option, using a biologic mesh, was not feasible at the time, as the available biologic meshes (Permacol and Strattice) were too thick for laparoscopic placement and would have required an open approach. The biologic meshes that were compatible with laparoscopy were absorbable within 12 months, and given the small size of the defect and the ability to achieve a tension-free primary repair, the use of absorbable mesh was deemed unnecessary. This approach aligns with literature findings which demonstrated that absorbable mesh can reduce recurrence in large hernias but is not always required in small, tension-free repairs [9]. If a laparoscopic-compatible permanent biologic mesh had been available, it would have been considered; however, due to the unexpected nature of the hernia, such materials were not stocked in advance in the hospital. The patient was clinically evaluated at the 2-week postoperative follow-up and was recovering well without any symptoms or complications. Planned follow-up included a 1-year postoperative visit to reassess the durability of the repair and to perform further evaluation based on clinical findings.

Discussion

LIMITATIONS:

This case report does have several limitations to recognize. First, this is a single-person design and not a large cohort, which limits generalizability and prevents the comparison of outcomes for laparoscopic, robotic, or open repair. In addition, long-term radiographic follow-up or standardized postoperative surveillance was not used, as recurrence is assessed based on symptomatology. Finally, the rarity of PHH limits the ability to draw broader conclusions regarding optimal operative approach or long-term outcomes.

Conclusions

FUTURE RESEARCH RECOMMENDATIONS:

While this case offers valuable clinical insight into individualized decision-making during PEH repair, further evidence is necessary to guide best practices. Future research should prioritize prospective cohort studies or multicenter investigations comparing operative approaches, including robotic and conventional laparoscopic techniques. Additional studies should evaluate primary suture repair with the use of synthetic and biologic meshes in atypical hernias with a focus on long-term outcomes, such as recurrence, postoperative complications, and quality of life. Furthermore, considering the technical limitations we encountered in terms of mesh availability and laparoscopic compatibility, it would be beneficial to investigate the utility, safety, and cost-effectiveness of biologic mesh in minimally invasive repair, particularly in unexpected or atypical hernias. Such studies will aid in the development of standardized guidelines and help optimize surgical strategies for patients with PHH.