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.
