We would like to acknowledge the Division of Thoracic and Foregut Surgery and the Department of Surgery at the University of Minnesota for helping us proceed with this study.

The protocol and methods described here were approved and followed the ethical guidelines of the Institutional Review Board (IRB) of the University of Minnesota. Described here is a reoperative hiatal hernia repair and takedown of a previous Nissen fundoplication in a 73-year-old woman. The patient presented to the clinic with a history of laparoscopic hiatal hernia repair and a fundoplication 5 years ago at an outside hospital for epigastric pain and fullness after meals. She also complained of significant reflux and dy...

Reoperative Hiatal Hernia Repair

<ol>
	<li>Awais, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reoperative+antireflux+surgery+for+failed+fundoplication:+an+analysis+of+outcomes+in+275+patients.">Reoperative antireflux surgery for failed fundoplication: an analysis of outcomes in 275 patients.</a> The Annals of Thoracic Surgery. 92 (3), 1083-1089 (2011).</li><li>Furnee, E. J., Draaisma, W. A., Broeders, I. A., Gooszen, H. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+reintervention+after+failed+antireflux+surgery:+a+systematic+review+of+the+literature.">Surgical reintervention after failed antireflux surgery: a systematic review of the literature.</a> Journal of Gastrointestinal Surgery. 13 (8), 1539-1549 (2009).</li><li>Singhal, S., Kirkpatrick, D. R., Masuda, T., Gerhardt, J., Mittal, S. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Primary+and+redo+antireflux+surgery:+outcomes+and+lessons+learned.">Primary and redo antireflux surgery: outcomes and lessons learned.</a> Journal of Gastrointestinal Surgery. 22 (2), 177-186 (2018).</li><li>van Beek, D. B., Auyang, E. D., Soper, N. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comprehensive+review+of+laparoscopic+redo+fundoplication.">A comprehensive review of laparoscopic redo fundoplication.</a> Surgical Endoscopy. 25 (3), 706-712 (2011).</li><li>Witek, T. D., Luketich, J. D., Pennathur, A., Awais, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Management+of+recurrent+paraesophageal+hernia.">Management of recurrent paraesophageal hernia.</a> Thoracic Surgury Clinics. 29 (4), 427-436 (2019).</li><li>Bathla, L., Legner, A., Tsuboi, K., Mittal, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+and+feasibility+of+laparoscopic+redo+fundoplication.">Efficacy and feasibility of laparoscopic redo fundoplication.</a> World Journal of Surgery. 35 (11), 2445-2453 (2011).</li><li>Pessaux, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+antireflux+surgery:+five-year+results+and+beyond+in+1340+patients.">Laparoscopic antireflux surgery: five-year results and beyond in 1340 patients.</a> The Archives of Surgery. 140 (10), 946-951 (2005).</li><li>Skinner, D. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+after+failed+antireflux+operations.">Surgical management after failed antireflux operations.</a> World Journal of Surgery. 16 (2), 359-363 (1992).</li><li>Nandipati, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reoperative+intervention+in+patients+with+mesh+at+the+hiatus+is+associated+with+high+incidence+of+esophageal+resection--a+single-center+experience.">Reoperative intervention in patients with mesh at the hiatus is associated with high incidence of esophageal resection--a single-center experience.</a> Journal of Gastrointestinal Surgery. 17 (12), 2039-2044 (2013).</li><li>Parker, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hiatal+mesh+is+associated+with+major+resection+at+revisional+operation.">Hiatal mesh is associated with major resection at revisional operation.</a> Surgical Endoscopy. 24 (12), 3095-3101 (2010).</li><li>Ashfaq, A., Rhee, H. K., Harold, K. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Revision+of+failed+transoral+incisionless+fundoplication+by+subsequent+laparoscopic+Nissen+fundoplication.">Revision of failed transoral incisionless fundoplication by subsequent laparoscopic Nissen fundoplication.</a> World Journal of Gastroenterology. 20 (45), 17115-17119 (2014).</li><li>Bell, R. C., Kurian, A. A., Freeman, K. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+anti-reflux+revision+surgery+after+transoral+incisionless+fundoplication+is+safe+and+effective.">Laparoscopic anti-reflux revision surgery after transoral incisionless fundoplication is safe and effective.</a> Surgical Endoscopy. 29 (7), 1746-1752 (2015).</li><li>Puri, R., Smith, C. D., Bowers, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+spectrum+of+surgical+remediation+of+transoral+incisionless+fundoplication-related+failures.">The spectrum of surgical remediation of transoral incisionless fundoplication-related failures.</a> Journal of Laparoendoscopic &amp; Advanced Surgical Techniques. 28 (9), 1089-1093 (2018).</li><li>Del Campo, S. E. M., Mansfield, S. A., Suzo, A. J., Hazey, J. W., Perry, K. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+redo+fundoplication+improves+disease-specific+and+global+quality+of+life+following+failed+laparoscopic+or+open+fundoplication.">Laparoscopic redo fundoplication improves disease-specific and global quality of life following failed laparoscopic or open fundoplication.</a> Surgical Endoscopy. 31 (11), 4649-4655 (2017).</li><li>Smith, C. D., McClusky, D. A., Rajad, M. A., Lederman, A. B., Hunter, J. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=When+fundoplication+fails:+redo.">When fundoplication fails: redo.</a> Annals of Surgery. 241 (6), 861-869 (2005).</li><li>Wilshire, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+outcomes+of+reoperation+for+failed+antireflux+operations.">Clinical outcomes of reoperation for failed antireflux operations.</a> The Annals of thoracic surgery. 101 (4), 1290-1296 (2016).</li><li>Zundel, N., Melvin, W. S., Patti, M. G., Camacho, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Benign Esophageal Disease: Modern Surgical Approaches and Techniques. , (2021).</li><li>Addo, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+revision+paraesophageal+hernia+repair:+a+16-year+experience+at+a+single+institution.">Laparoscopic revision paraesophageal hernia repair: a 16-year experience at a single institution.</a> Surgical Endoscopy. 37 (1), 624-630 (2023).</li><li>Autorino, R., Zargar, H., Kaouk, J. 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G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=635+robotic+redo+funduplication+for+a+two+time+recurrent+hiatal+hernia.+How+we+do.">635 robotic redo funduplication for a two time recurrent hiatal hernia. How we do.</a> Diseases of the Esophagus. 34 (Supplement_1), (2021).</li><li>Soliman, B. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+hiatal+hernia+repair+demonstrates+favorable+short-term+outcomes+compared+to+laparoscopic+hiatal+hernia+repair.">Robot-assisted hiatal hernia repair demonstrates favorable short-term outcomes compared to laparoscopic hiatal hernia repair.</a> Surgical Endoscopy. 34 (6), 2495-2502 (2020).</li><li>Tolboom, R. C., Draaisma, W. A., Broeders, I. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+conventional+laparoscopic+versus+robot-assisted+laparoscopic+redo+hiatal+hernia+and+antireflux+surgery:+a+cohort+study.">Evaluation of conventional laparoscopic versus robot-assisted laparoscopic redo hiatal hernia and antireflux surgery: a cohort study.</a> Journal of robotic surgery. 10, 33-39 (2016).</li><li>Jamieson, J. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ambulatory+24-h+esophageal+pH+monitoring:+normal+values,+optimal+thresholds,+specificity,+sensitivity,+and+reproducibility.">Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity, and reproducibility.</a> American Journal of Gastroenterology. 87 (9), 1102-1102 (1992).</li><li>Johnson, L. F., DeMeester, T. 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Reoperative foregut surgery is technically challenging but can be performed safely with a well-planned and thoughtful surgical approach. A thorough preoperative evaluation is essential to determine the etiology of symptoms and to guide diagnostic adjuncts. It is of utmost importance to determine the correct diagnosis prior to reintervention in order to determine the proper surgery and approach. For example, in patients undergoing redo&#160;anti-reflux&#160;surgery (ARS) after Nissan fundoplication, one should understand ...

Over the past century, improvements in the understanding and diagnosis of foregut disorders have led to the evolution of better procedures and surgical approaches. This innovation brings new challenges related to complications and reoperation for the foregut surgeon. Surgical reinterventions are particularly challenging from a technical perspective due to multiple factors, including dense adhesions, scarring, obliteration of tissue planes, and altered anatomy1,2,3,4,5. These redo foregut surgeries&#160;have increased morbidity in patients with higher incidences of esophageal perforation, delayed gastric emptying, and vagal nerve injury1,6,7,8. Mesh repairs at the hiatus complicate reintervention further, having higher rates of major resection requiring complex reconstruction9,10. The advent of advanced endoscopic therapies creates ever-evolving challenges for foregut surgeons when dealing with their associated complications or failures11,12,13. Furthermore, redo foregut operations are associated with worsening success rates and patient satisfaction with successive reoperations compared with primary intervention14,15,16,17. This highlights the importance of patient selection and accurate diagnosis prior to redo surgery for optimal outcomes.
While traditionally performed using an open approach, laparoscopic approaches to redo foregut surgery are safe and efficacious14,18. However, due to the greater difficulty associated with altered anatomy and adhesions, conversion to open surgery is still a possibility. With the emergence of robot-assisted surgery in urology and gynecologic surgery19,20, the superior visualization and dexterity compared to laparoscopy would appear to likely have some benefit in redo foregut surgery as well. Indeed, emerging research has shown safety and improved outcomes, including less conversions to open surgery and decreased hospital stays compared with the laparoscopic approach for redo foregut surgery21,22,23.
Although it is ultimately up to the foregut surgeon to determine the safest procedure, this article aims to demonstrate the approach and technical considerations for redo foregut surgery to provide a &#34;framework&#34; when confronted with this challenge. While a robotic-assisted approach is described, the principles described could be similarly applied to laparoscopy.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Bravo calibration-free reflux testing system</td>
			<td>Medtronic</td>
			<td>FGS-0635</td>
			<td>Wireless esophageal pH testing system</td>
		</tr>
		<tr>
			<td>Cadiere forceps</td>
			<td>IS</td>
			<td>470049</td>
			<td>Used as a grasper</td>
		</tr>
		<tr>
			<td>da Vinci Surgeon Console</td>
			<td>IS</td>
			<td>SS999</td>
			<td>Used to control surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Vision Cart</td>
			<td>IS</td>
			<td>VS999</td>
			<td>Houses advanced vision and energy technologies to provide communication across the platform components</td>
		</tr>
		<tr>
			<td>da Vinci Xi</td>
			<td>IS</td>
			<td>K131861</td>
			<td>The surgical robot</td>
		</tr>
		<tr>
			<td>da Vinci Xi Endoscope with Camera, 8 mm, 30&#176;</td>
			<td>IS</td>
			<td>470027</td>
			<td>The camera for the da Vinci robot</td>
		</tr>
		<tr>
			<td>Lapro-Flex Articulating Retractors</td>
			<td>Mediflex</td>
			<td>91682</td>
			<td>Used as liver retractor</td>
		</tr>
		<tr>
			<td>Large needle driver</td>
			<td>IS</td>
			<td>470006</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 56 Fr</td>
			<td>Pilling</td>
			<td>507956</td>
			<td>Esophageal bougie for hiatal repair</td>
		</tr>
		<tr>
			<td>Maloney Tapered Esophageal Bougie, 58 Fr</td>
			<td>Pilling</td>
			<td>507958</td>
			<td>Esophageal bougie for wrap creation</td>
		</tr>
		<tr>
			<td>Mega SutureCut needle driver</td>
			<td>IS</td>
			<td>470309</td>
			<td>Used as a needle driver</td>
		</tr>
		<tr>
			<td>Monolithic FlexArm Plus</td>
			<td>Mediflex</td>
			<td>99045-QC</td>
			<td>Used to hold liver retractor to OR bed</td>
		</tr>
		<tr>
			<td>Round tip scissors</td>
			<td>IS</td>
			<td>470007</td>
			<td>Used for cutting</td>
		</tr>
		<tr>
			<td>Shiley Hi-Lo oral/nasal endotracheal tube cuffed, 8.0 mm</td>
			<td>Covidien</td>
			<td>86113</td>
			<td>Endotracheal tube for intubation</td>
		</tr>
		<tr>
			<td>SynchroSeal</td>
			<td>IS</td>
			<td>480440</td>
			<td>Used for dissecting, vessel sealing, and dividing</td>
		</tr>
		<tr>
			<td>Tip-Up fenestrated grasper</td>
			<td>IS</td>
			<td>470347</td>
			<td>Used as a grasper</td>
		</tr>
	</tbody>
</table>

technical considerations and approach to redo foregut surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Technical Considerations and Approach to Redo Foregut Surgery

Our research focuses on thoracic surgery with specific regard to reoperative foregut operations. A large portion is surgical outcomes-based research, but we also emphasize quality improvement in surgery, such as with this protocol. In this video, we discuss our approach to reoperative foregut surgery.In foregut surgery, technological advances continue to be made in the intraop and pre-op settings. Improvements in diagnostic technology, such as with the Endoflip system and high resolution manometry provide more accurate information in diagnoses of the foregut, while robotic technology and intraop monitoring help us provide the best care possible in surgery. Most literature, looking at reoperative foregut surgery emphasizes the outcomes but not necessarily the approach to performing the operation.We describe a step-by-step approach to the operation, while maintaining the general principles broadly, and thus, providing a reference for other foregut surgeons. In the future, we will continue to focus on reviewing outcomes of other reoperative foregut surgeries with the goal of developing guidelines and standardizing the management of these cases.

The patient had an uneventful postoperative course. She slowly advanced to a full liquid diet over a period of 3 days and was then discharged on a liquid diet with instructions to advance to a soft diet after 1 week.
By virtue of being a quaternary referral center and a major university hospital, we frequently manage patients needing reoperative foregut surgery. Our data from the last 5 years with 43 patients undergoing reoperative hiatal hernia repairs showed a mean length of stay of 7 days a...

Watch this Scientific Journal Video about Technical Considerations and Approach to Redo Foregut Surgery at JoVE.com

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

technical-considerations-and-approach-to-redo-foregut-surgery

Research

JoVE Journal

Medicine

Robotic Reoperative Hiatal Hernia Repair After Post-Laparoscopic Procedure

To begin, position the anesthetized patient supine with arms out and a footboard to facilitate steep reverse Trendelenberg positioning. Using the open hasson technique, enter the peritoneal cavity in the left supra umbilical space to insert the camera port. Next, insert one eight millimeter port in the right upper quadrant, 10 centimeters above the umbilicus, and one port in the left upper quadrant.Place the assistant port in the right lower quadrant. Insert the liver retractor through a five millimeter port, placed in the extreme lateral part of the right upper quadrant. Then dock the surgical robot.To reduce hiatal hernia, begin by removing the adhesions of the bowel to the abdominal wall. Then, using a robotic bipolar surgical energy device, open the gastrohepatic ligament. Open the lesser sac by removing adhesions and additional short gastric artery branches.Using a combination of blunt and electrocautery dissection with the robot, dissect the hernia sac, circumferentially at the hiatus. Then use laparoscopic scissors to carefully dissect the dense adhesions between the liver and stomach. To note previous fundoplication, perform sharp dissection with laparoscopic scissors and undo the wrap to completely free the stomach.Next, using the combination of blunt and sharp dissection, mobilize the esophagus, transhiatally in the mediastinum. Under endoscopy, identify the gastroesophageal junction, then measure the esophagus from the hiatus to the gastroesophageal junction. Next, perform endoscopy and visualize the mucosa clearly to ensure no injuries and insufflate the esophagus in stomach to ensure no air leakage.Begin hiatal repair by performing accrual repair using O silk sutures, applying two to three posterior crural stitches. Pass a 56 French bougie into the esophagus, and with the bougie in place, pass a grasper comfortably into the hiatus. Next for Nissen fundoplication, bring the fundus across the right side, posterior to the esophagus and beneath the vagus nerve.Pass a 58 French bougie into the esophagus and perform a loose fundoplication over the bougie, using three 2/0 silk sutures.

311 Views.  University of Minnesota.  Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Reoperative Hiatal Hernia Repair

Summary