Giant hernias are usually observed in elder patients and can become a real obstacle in their lives causing a plethora of problems, which in rare scenarios can cause symptoms from the heart and lungs, such as shortness of breath or chest pain.

That was the case with our 68-year-old patient, who was diagnosed with a giant hiatal hernia, in which the stomach, part of the duodenum (the first part of the small intestine), the transverse colon and the omentum were protruding into the thoracic cavity, above the diaphragm and behind the heart.

This case is of great interest, due to its rarity and complexity, its method of treatment and the outcome which came with rapid recovery and minimal blood loss with the use of the robotic system Da Vinci Xi.

Case Presentation

The 68-year-old patient presented with a series of problems related to his giant hiatal hernia, such as difficulty in swallowing his food, gastroesophageal reflux, difficulty in his breathing with pain behind the sternum, as well as struggle in falling asleep while lying on his back. These problems kept getting worse daily, greatly reducing his quality of life.

The diagnosis and classification of this giant hiatal hernia was based on endoscopy, X-ray and manometry (exam that measures the esophageal pressure).

The repair was carried out through a pioneering robotic fundoplication procedure, which took about 4 hours, although typical robotic hiatal hernia repairs usually take 1 to 2 hours in total.

Thanks to the unparalleled access the robotic system provides and the way it facilitates the dexterity and facility with which complex dissections can be carried out, this giant hiatal hernia was completely repaired with minimal blood loss.

The special feature of this robotic operation is that the combined incisions to the patient’s abdomen and chest were avoided. The entire operation was performed through small holes of 5-7 mm diameter in the abdomen.

As a result, the patient did not go to the intensive care unit, which in other cases would have been necessary and for a long period of time.

Conclusion

The 3D imaging and the large magnification of the surgical field, as well as the possibilities offered by the robotic technology together with our experience of more than 2,000 operations to treat hiatal hernia and gastroesophageal reflux disease, were essential in the case of this particular patient, so that the problem can be remedied successfully and without complications.

About Hiatal Hernia

Hiatal hernia is a common condition, the incidence of which increases over the years reaching up to 50% of the population over the age of 70.

In Hiatal Hernia, anatomical structures of the abdomen, such as the stomach, are pushed into the chest cavity, through a gap in the diaphragm, the skeletal muscle that separates the abdomen from the chest.

There are two main types of hiatal hernia, the sliding one, which is the most common and refers to small and sometimes asymptomatic hernias that may not require surgical treatment, and the paraoesophageal, which refers to a projection of the dome of the stomach above the diaphragm and therefore considered more dangerous.

The main symptom of a sliding hiatal hernia is gastroesophageal reflux, i.e., when stomach contents turn back and find their way into the esophagus.

On the other hand, complications of paraoesophageal hernias may include bleeding, respiratory distress and gastric torsion, a surgical emergency.

Therapeutic Challenges

The laparoscopic approach is becoming more and more common and is now the operation of choice for hiatal hernia repair.

However, while the repair of small and symptomatic sliding hiatal hernia with conventional laparoscopic surgery has been well described and has yielded satisfactory results, the same cannot be said for giant hiatal hernia.

Repair of giant hiatal hernia with conventional laparoscopic surgery remains a challenge due to the rarity and complexity of this condition.

Robotic surgery is the answer to the challenges and technical difficulties that accompany conventional laparoscopic reconstruction.

Thanks to the assistance of the Da Vinci XI robotic system, the restoration of the giant hiatal hernia can be achieved with absolute success, without complications from the surgery and with all the benefits of a minimally invasive procedure: minimal blood loss, minimal post-operative pain and an immediate return to everyday life.

The case of the 68yo with a giant hiatal hernia is indicative of the difference that using the Da Vinci Xi robotic system can make.

A 56-year-old male patient complained for red right blood in his stools and colonoscopy revealed a rectal cancer 6 centimeters above the anal verge. Preoperative tumor staging confirmed there was benefit for neoadjuvant chemoradiation therapy. The patient had 3 options:

Open surgery with high chance of permanent end colostomy
Laparoscopic surgery
Robotic Surgery, which was our choice of treatment
6 weeks after induction of neoadjuvant therapy the tumor had downstaged properly and the patient was scheduled for a robotic operation with intend to cure.

The patient underwent a robotic ultra-low anterior resection with primary anastomosis. The operation consists of removing the lower part of the rectum and restoring the continuity of the bowel. The cornerstone of the treatment is to sufficiently remove the mesorectum and perform a complete total mesorectal excision, meaning to remove all the surrounding fat of the rectum which included the lymph nodes and vessels. By properly removing the mesorectum we succeed in greatly reducing the risk of local recurrence.

The operation was carried out with the da Vinci Xi robotic platform in Athens Medical Center and the outcomes were excellent.

Blood loss was minimal and post-operative recovery was remarkable. In the first two post-operative days the patient’s bowel started moving and he was physically active.

The immediate recovery and return to daily routine after robotic operations in addition to our vast experience proves that this technology maximizes benefits and advantages with the less possible stress for the patients.

Advantages

Robotic operations are usually bloodless, with low post-operative pain and quick recovery. This minimizes the risk of post-operative complications such as blood clots causing pulmonary embolism or respiratory and urinary infections.

Also, robotic surgery has less hospital stay compared to conventional techniques. As far as rectal cancer operations are concerned, robotic technology allows for faster induction of adjuvant chemotherapy if needed compared to open surgery which requires triple that delay.

In the past years, all conferences and scientific meetings are focusing on minimally invasive techniques to address cancer cases. Laparoscopy used to be the choice of treatment in the past and robotic approach nowadays.

Robotic surgery confers overall the most benefits for the patient with better outcomes and less complications and this is the reason why patients trust me and my surgical team in Athens Medical Center for their oncologic surgical treatment.

A 76-year-old female patient was diagnosed with acute biliary cholecystitis and needed medical help due to right upper quadrant pain. The decision to remove the gallbladder as soon as possible was taken. At the same time the patient had a gynecologic hemorrhage and was consulted by a gynecologist prior to our operation. After screening the patient was also diagnosed with uterus cancer.

To address both diseases effectively at the same time we chose the robotic approach. First, we would remove the gallbladder and then we would perform a total hysterectomy. Our choice was based on the benefits of robotic surgery such as

Removal of the omentum
Removal of the ovaries, of the tubes and the uterus
Total lymph nodes harvest
Benefits

The choice of robotic approach for this demanding case had several advantages:

Blood loss was minimal, no big incisions in the abdomen and the patient’s recovery was fast: discharged within 48 hours.
The lymph node harvest was optimal as all lymph nodes located in nearby major vessels, withing the pelvis and in the omentum were removed.
The patient was morbidly obese and the robotic approach in addition to our vast experience results in nearly 0% conversion rate to open surgery.
The fact that we were able to perform 2 different operations, have a full lymph node harvest and being able to thoroughly explore the abdominal cavity without an incision in the abdomen proves the superiority of the robotic technology. Our experience is clearly shown in such cases as we routinely perform robotic abdominal operations in Athens Medical Center since 2006 under the direction of world renowned prof. K. Konstantinidis, who first used the robotic platform in Greece.