Paraesophageal hernias and Nissen fundoplication

A paraesophageal hernia is a common diagnosis with surgery as the mainstay oftreatment. A minimally invasive approach facilitates increased visualization whiledecreasing the morbidity of an open procedure. The key steps in paraesophageal herniarepair are reduction of the hernia sac, complete dissection of both crura and thegastroesophageal junction, tension free reapproximation of the hiatus, and esophageallengthening to achieve at least 3 cm of intra-abdominal esophagus. This chapter examinesthe surgical approach to paraesophageal hernias with special reference to the evolutionand practicality of using a robotic approach. Appropriate positioning and set-up as well ashaving a team experienced with use of the robot are the keystones to a successfuloperation. The robot is typically docked over the head of the bed with the trocarsseparated by 10cm to avoid robotic arm collision while keeping them superior enough tofacilitate mediastinal dissection if that becomes necessary. Improved visualization andmobility with the use of the robot can aid in the mediastinal dissection and subsequentlyprovide better esophageal lengthening.