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Ugliono et al. Mini-invasive Surg 2021;5:2 I http://dx.doi.org/10.20517/2574-1225.2020.93 Page 3 of 12

Open vs. minimally invasive approach
The conventional open approach to PEH repair, through a thoracotomy or a laparotomy, was associated
with a high rate of morbidity (5.3%-25%) and mortality (0%-3.7%). The main complications described
[13]
were pneumonia (2.6%, range 2.1%-8.7%) and wound infections (5.8%, range 0.8%-8.7%) . Since the
[14]
introduction of the laparoscopic technique to PEH treatment by Cuschieri in 1992, the minimally
invasive approach has spread rapidly. Several population-based studies demonstrated a significant
reduction in hospital stay, intensive care unit stay, postoperative morbidity, mortality, and overall costs
of laparoscopic PEH repair compared to the conventional open approach [15,16] . Therefore, laparoscopy is
considered the preferred surgical access for PEH repair, including in the emergency setting [5,17] .

More recently, the robotic platform has been proposed for surgical PEH treatment. The evidence
regarding robot-assisted repair of PEH consists of small retrospective series of single institutions in their
early experience with this technique, and no long-term follow-up is available. These studies described
a postoperative morbidity of 15%-23% and a mortality rate of 0%-2.5%, which are comparable with the
outcomes of the laparoscopic series reported in the literature [18-20] .

However, no studies specifically assessing the comparison of robot-assisted and laparoscopic approaches to
PEH repair have been conducted, and no clear benefits of the robotic approach have been elucidated yet.
Therefore, the role of robotics in the surgical management of PEH remains controversial.

SURGICAL PRINCIPLES
The essential technical steps of the procedure consist of complete reduction of HH, hernia sac excision,
extensive mediastinal mobilization of the esophagus, and tension-free crural closure.

The first step of the procedure is the abdominal reduction of HH contents by gentle traction of the hernia
sac, proceeding gradually with extensive mediastinal mobilization of the esophagus with blunt dissection in
[21]
order to obtain at least 2-2.5 cm of intra-abdominal esophageal length [Figure 1A and B] .
During hernia sac dissection, caution must be used to prevent injury to the vagal nerves on the anterior
[22]
and posterior aspect of the esophagus, to the pleura, and to the adjacent vascular structures [Figure 2] .

After complete reduction, sac excision is imperative [Figure 3]. A tension-free closure of the diaphragmatic
crura must be achieved with crural approximation with or without mesh [Figure 4A and B]. Additional
technical steps, such as fundoplication, esophageal lengthening, gastropexy, and relaxing incisions, have
been investigated to improve the results of PEH repair and are discussed below.

The most common intraoperative complication reported is visceral injury (esophageal and gastric
perforations), which is reported in up to 11% of cases, followed by vagal nerve injury and pulmonary
complications (pneumonia) .
[23]

Sudden increases in intra-abdominal pressure in the immediate postoperative period, due to coughing,
[24]
belching, vomiting, and lifting weights, have been shown to contribute to PEH recurrence . Therefore,
[5]
postoperative nausea and vomiting must be treated aggressively .
Routine early upper gastrointestinal series before starting diet is unhelpful in the absence of suspicious
clinical signs, as it has been shown that it would change the clinical management of patients in only 0.8% of
[25]
cases .