Comparison of laparoscopic vs. robotic paraesophageal hernia repair: a systematic review

Introduction

A hiatal hernia (HH) is the herniation of abdominal contents into the mediastinum through the diaphragm. There are four types of HHs (I–IV) (1,2). Paraesophageal hernia (PEH) is a rare (5–10% of all HHs) type of HH, in which the abdominal viscera herniates through the dilated diaphragmatic hiatus along with the esophagus (2,3). The incidence of PEH increases with age, thus with an aging population an increase in the overall incidence of PEH may be expected (3). Treatment options range from watchful waiting, pharmacological management for symptom control, and surgical repair (1,4). A wide array of surgical techniques to repair PEH have been developed. With the advent of minimally invasive surgery (MIS), there has been an overall improvement in patient outcomes in terms of morbidity and mortality when compared to trans-thoracic and trans-abdominal open surgical procedures (5,6). The first laparoscopic PEH repair was performed in 1990 and over the years, it has become the gold standard surgical treatment choice for PEH (3,7). Despite ongoing advancements in laparoscopic instruments, there still are technical challenges which surgeons can encounter, such as limited mobility to work in small spaces and reach challenging angles, 2-D image visualization, and suboptimal camera handling or motion (4,6). To overcome some of the shortcomings of laparoscopic surgery, robotic surgical solutions have been developed. These modalities have a unique set of advantages over traditional laparoscopic MIS, including improved mobility to work in small spaces to reach challenging angles, improved ergonomics, and 3-D image visualization. However, robotic surgery has its own disadvantages, such as longer operative time and increased cost and complexity (8). Though laparoscopic PEH repair is generally considered superior to the open approach, the increasing popularity of robotic PEH repair has led to a debate on which approach represents the optimal form of MIS (5). There is limited data on laparoscopic versus robotic PEH repair and no known randomized controlled trials. The aim of this study was to compare laparoscopic versus robotic PEH repair with regards to perioperative outcomes. We present the following article in accordance with the PRISMA reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-819/rc).

Methods

A comprehensive search of several databases from each database’s inception to May 11th, 2022, in English was conducted. The databases included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. The search strategy was designed and conducted by a researcher with input from the study’s principal investigator, and no help was sought from a biomedical librarian. Controlled vocabulary supplemented with keywords was used to search for robotic vs. laparoscopic PEH repair in humans, keywords used: “esophageal hernia”, “hiatal hernia”, “hiatus hernia”, “oesophageal hernia”, “paraesophageal hernia”, “paraoesophageal hernia”, “Robotic Surgery”, “Robotic Surgical”, “robot*”, “Laparoscopy”, “keyhole” or “key-hole” or “Laparoscop*” or “minimally invasive surg”. This search eventually yielded 384 articles. The actual strategy listing all search terms used and how they are combined is available in the appendix (see Appendix 1).

The inclusion and exclusion criterion were as follows. Studies were included using the following criteria: (I) all articles related to PEH repair; (II) peer reviewed articles; (III) articles published in the last 10 years; (IV) articles in English; (V) full text articles; (VI) study population—humans; (VII) age—above 18 years. Studies were excluded using the following criterion: (I) papers unrelated to PEH repair; (II) non peer reviewed articles including grey literature (master’s thesis, white papers); (III) unpublished literature including abstracts, conference abstracts; (IV) articles older than 10 years; (V) articles not in English; (VI) articles on pediatric patient population. After applying the inclusion and exclusion criteria, we were left with 7 articles. Assessment for bias and risk was done using Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa Scale, respectively. Data analysis of demographics and perioperative outcomes such as operative time, intraoperative complications, length of stay, perioperative complications and mortality, recurrence, cost, and patient reported outcomes from all the studies were included in this systematic review using a narrative synthesis approach.

Results

We retrieved a total of 384 published articles during the initial search. After removing duplicates and eliminating publications based on eligibility criteria, 7 studies were selected for analysis from a total of 384 articles found in the database search (Figure 1).

Figure 1 PRISMA flow chart.

Synthesis of results

Narrative synthesis has been provided for the findings obtained from the studies. The data extracted has been presented in a tabular form in Table 1.

Ultimately our review included 171,093 patients from seven observational studies. Generally, in these studies, retrospective analysis of prospectively collected data was being used to identify patients undergoing PEH repair either laparoscopically or robotically. This data was then used to compare their perioperative outcomes. Demographics, clinical characteristics, and perioperative outcomes from the included studies are given in Table 2.

Operative time/intraoperative complications

In a prospective comparative clinical study by Wilhelm et al., 55 patients underwent complete upside-down stomach (cUDS) hernia (subgroup of HH) repair. The median operation time was significantly higher for robotic approach vs. laparoscopic approach (232 vs. 163 min) (9). Similarly, longer operative time [median (IQR), 186.5 (152.0, 232.0) vs. 158.0 (132.0, 188.0) min; P≤0.001] was seen in the study by Soliman et al., whereas Gerull et al., found a statistically significant shorter operative time in robotic PEH repair [mean (SD), 174.1 (±63.8) vs. 187.3 (±65.3) min; P≤0.001] (12,13). On the other hand, two studies found no difference in the operative times between robotic and laparoscopic approach (10,11). One study noted a higher rate of intraoperative complications for a robotic approach as compared to a laparoscopic approach (0.6% vs. 2.7%, P<0.001) (6).

Length of stay

A significant decrease was found in the length of hospital stay following robotic PEH repair as opposed to laparoscopic PEH repairs (11-13). Four studies denote no difference and even a possible increase in hospital stay in robotic PEH repair, but all these findings were statistically insignificant (2,8-10).

Perioperative complications/mortality

A retrospective study by Ward et al., among 168,329 patients undergoing PEH repair between 2010–2015 reported overall adjusted rate of complications to be significantly higher in robotically assisted patient’s vs. laparoscopic surgery, even in high-volume centers (8). Postoperative complication rates in the robotic surgery group were similar to the laparoscopic surgery group in one study, but a higher postoperative complication rate was associated with laparoscopic technique in another (10,12). A retrospective study by Soliman et al., on 293 patients who underwent elective PEH repair found significant reductions in complication rates in the robotic surgery group (6.3 vs. 19.2%), whereas three other studies state no significant difference in postoperative complication rate (2,10,11). No statistical difference was found in reoperations, readmission rates and mortality between the modes of MIS (2,11,12).

Recurrence

A yearlong follow up showed significantly lower recurrence rates after robotic repair (13.3% vs. 32.8%). Consideration needs to be made regarding mean follow up differences between robotic approach vs. laparoscopic approach (23.7±28.4 vs. 15.1±14.9 months) (11). Robotic PEH repair was associated with a significant decrease in esophageal lengthening procedures being performed (0.1% vs. 11.0%), and conversion to open procedures (13).

Cost

Intraoperative costs were similar between robotic vs. laparoscopic repairs, whereas higher costs overall were associated with robotic PEH repairs (8,13).

Patient-reported outcomes

Patients in the study by Wilhelm et al. had similar GERD-HRQL scores regardless of the approach to repair PEH (9).

Risk of bias assessment

The Cochrane Risk of Bias Assessment Tool was used to assess the risk of bias. Individual factors from five domains are given a score (high, low, or unclear) to determine bias (selection, performance, attrition, reporting, and other). Using the guidance provided at the end of the form, risk of bias was selected as “high”, “low” or “unclear” for each judgment. A detailed description about the risk of bias assessment is provided in Table 3.

Discussion

One large 2012 study demonstrated that minimally invasive techniques account for 80% of surgical interventions for PEH (14,190 out of 17,830 procedures) (5). The advantages of MIS over open surgery include decreased pain, faster postoperative recovery, and lower morbidity. Over the last three decades, a laparoscopic approach for HH repair has become the gold standard procedure. Robotic surgery has been gaining popularity ever since the Food and Drug Administration (FDA) approved the DaVinci robotic surgical system for clinical use in the year 2000. Improved visualization, ergonomics, and additional degrees of freedom of the instrumentation has resulted in accelerating usage of robots in numerous surgical subspecialties. Despite these advantages, the entrance of robotic techniques into these different surgical subspecialties has not always resulted in improved outcomes (14,15).

The focus of our work was to compare robotic and laparoscopic PEH repair in the existing literature. Given the lack of any randomized trials comparing laparoscopic and robotic PEH repair, we decided to conduct a systematic review, which included seven articles with a total of 171,093 patients (160,005 laparoscopic repairs and 11,075 robotic repairs) published between 2012 and 2022. Patient demographics were similar to the previous studies including an average age 63.7 year and sex with female preponderance, making up to 67.5% of the study population (16), making our study results applicable to the typical patient population presenting for PEH; 168,329 of these patients were included in a single study, which deserves further comment (8). In this study, the difference in perioperative complication rate was driven mainly by an increased risk of esophageal perforation (OR 2.19, 95% CI: 1.42–3.93) and respiratory failure (OR 1.68, 95% CI: 1.37–2.05). The increased complication rate applied to even high-volume centers (defined by >20 operations/year), however the clinical significance of a 12.6% vs. 10.4% overall complication rate among high-volume centers is likely minimal. In addition, the years 2010–2015 would be considered relatively early in the worldwide experience of robotic PE repair, given that the earliest series of robotic PEH repair were published in 2008 (17,18). Nonetheless, this large, “real world” study demonstrates that robotic PEH repair may have some disadvantages, especially for those early in their experience.

Most of the other studies we analyzed, however, showed comparable if not favorable perioperative outcomes when comparing robotic to laparoscopic surgery (19-21). Robotic PEH repair demonstrated equivalent or superior hospital length of stay, compared to laparoscopic PEH repair. Perioperative outcomes were generally similar as a whole, though individual studies did show an improved complication rate, decreased conversion rate, lower recurrence rate, and decreased rate of esophageal-lengthening procedures in the robotic group compared to the laparoscopic group. Laparoscopic redo PEH repair conversion rates have been reported to be as high as 11% in the literature (13,16). Prior HH repair was more likely in robotic cases in four of the studies, and all of the studies in which this variable was reported (Howell, 20.4% vs. 5.9%, P=0.042; Soliman, 21% vs. 7.9%, P<0.00; Gerull, 32.5% vs. 24.2%, P<0.001; O’Connor, 24% vs. 12.9%, P=0.08) (2,6,11,12). The fact that near equivalent perioperative results were achieved in the robotic cohort in spite of a higher likelihood of reoperative PEH repair should be noted.

Limitations of our study include the non-randomized and retrospective nature of the studies included; therefore, selection bias could play a role in terms of influencing the results. Selection bias could favor either robotic or laparoscopic PEH repair; it was impossible to determine the relative size or complexity of hernias in patients who underwent robotic vs. laparoscopic PEH repair. One could argue that surgeons would be more likely to offer repair to patients with more sizeable hernias on the robotic platform, which has some advantages in terms of camera maneuverability (a significant concern in PEH repair, which is a transabdominal operation that takes place primarily in the chest) and control of retraction (no need for a potentially inexperienced assistant to retract). On the other hand, it is possible that surgeons early in their robotic experience may have preferred to perform “difficult” cases laparoscopically. A significant learning curve may be seen when transitioning toward robotic surgery. Unsurprisingly, shorter operative times are linked with an increased number of operations performed by a surgeon (22,23). The study by Lin et al., describe the transition into three phases. Phase 1 included cases 1 to 40 and had an increasing console time (CT). Phase 2, the improvement phase included cases around 41 to 84, and reflected a plateau in terms of CT. Phase 3, the mastery stage was seen at around 85 cases with a decrease in CT (22). These learning curves should be kept in mind while comparing laparoscopic and robotic approaches. Many robotic studies reflect the entire experience of the investigators, which includes cases done in the early and improvement phases cited above.

Another weakness is the inability to control for inter-operator variability between different providers in different studies (10,22). In addition, there could be an era effect that partially explains some of the improved outcomes seen in robotic PEH repair. Generally speaking, surgeons are more likely to transition from laparoscopic PEH repair to robotic PEH repair than from robotic to laparoscopic; therefore, lessons learned and experience gained over time with regards to both intraoperative conduct of PEH repair and perioperative management would be more likely to favor robotic approaches.

Finally, due to the small number of studies for this research question, heterogeneity and sensitivity analyses for comparison of variables between the studies was not feasible.

As in many other procedures, robotic surgery is increasingly utilized for PEH repair; for now, however, the existing evidence shows that most perioperative outcomes are comparable between the robotic and laparoscopic approaches.

Conclusions

When compared to traditional laparoscopic techniques, robotic surgical treatment of PEH may provide the surgeon with enhanced dexterity and comparable outcomes. Current evidence generally demonstrates that robotic HH repairs may be linked to a decrease in hospital stay, lower recurrence rate, fewer conversions to open, and less of a need for esophageal lengthening procedures. Conversely, PEH repairs may be associated with higher complication rates and overall cost. More studies, ideally in a randomized fashion, are needed to compare laparoscopic and robotic PEH repair. Given the fact that equipoise between the two techniques is unlikely for any given surgeon or even institution, however, assessing these competing methods may depend on large, multi-center propensity-matched cohorts studies.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-819/rc

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-819/coif). BW serves as an unpaid editorial board member of Journal of Thoracic Disease from October 2022 to September 2024. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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