Minimally invasive hiatal hernia repair: a single-institution experience and evolving surgical trends
Fadi Alsayegh1, Jessica E. Wahi1
, Jacob Kalathoor2, Fernando M. Safdie1
Contributions: (I) Conception and design: JE Wahi, FM Safdie; (II) Administrative support: All authors; (III) Provision of study materials or patients: FM Safdie; (IV) Collection and assembly of data: F Alsayegh, JE Wahi; (V) Data analysis and interpretation: F Alsayegh, JE Wahi, FM Safdie; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Background: Hiatal hernias are common and often require surgical intervention, particularly in symptomatic patients. Minimally invasive approaches, including laparoscopic and robotic techniques have shown superiority over open surgery. However, data on evolving institutional practices and outcomes remain limited. This study aims to describe perioperative outcomes and evolving surgical practices in patients undergoing minimally invasive hiatal hernia repair (HHR) at a single institution between 2018 and 2024.
Methods: A retrospective, chart-based review was conducted on patients who underwent minimally invasive HHR between 2018 and 2024 by a single surgeon at Mount Sinai Medical Center in Miami Beach, Florida. Patient demographics, operative details, and perioperative outcomes—including operative time, length of stay (LOS), readmission rates, complications, and symptom resolution were analyzed. Trends in surgical approach and technique over time were also assessed.
Results: The cohort had a mean age of 69 years and a mean body mass index (BMI) of 26.6 kg/m2. Most patients underwent elective repair (86%, n=95) and the robotic platform was utilized in 82% (n=91) of cases, reflecting a growing institutional preference over time. The overall mean operative time was 194 minutes, with a downward trend as robotic proficiency increased. Median hospital stay was two days and 83% (n=84) of patients reported complete symptom resolution at 6-month follow-up. Readmission occurred in 10% (n=11) of cases, with no conversions to open surgery or perioperative mortality. Mesh reinforcement was used selectively in only one patient.
Conclusions: Minimally invasive HHR is safe and effective, with low complication rates and high rates of symptom resolution. This study highlights a successful institutional transition toward robotic HHR with improvements in operative efficiency and LOS over time.
Keywords: Hiatal hernia repair (HHR); minimally invasive surgery; robotic surgery; surgical trends; perioperative outcomes
Received: 10 May 2025; Accepted: 01 September 2025; Published online: 26 September 2025.
doi: 10.21037/aoe-25-17
Highlight box
Key findings
• A total of 111 minimally invasive hiatal hernia repairs (HHRs) were performed between 2018 and 2024, with a mean patient age of 69 and BMI of 26.6 kg/m2.
• The majority of cases (86%) were elective and 82% were performed robotically, reflecting an institutional shift over time toward robotic surgery.
• Median length of stay was two days with 65% of patients being discharged by postoperative day two.
• Symptom resolution at 6-month follow up was achieved in 83% of patients with a 10% readmission rate.
• There were no conversions to open surgery and mesh reinforcement was used selectively in only one case.
What is known and what is new?
• Minimally invasive techniques—both laparoscopic and robotic—are standard for HHR, with benefits over open surgery. The optimal surgical approach remains debated.
• This study provides real-world data from a single institution, highlighting the safe and effective use of minimally invasive techniques with an evolving preference toward robotic surgery and associated gains in operative efficiency.
What is the implication, and what should change now?
• The findings support continued adoption of minimally invasive techniques, including robotic platforms, for HHR. Selective use of mesh and tailored approaches to fundoplication and cruroplasty should be guided by patient anatomy, comorbidities and surgeon experience. Long-term follow-up and cost-effectiveness studies are warranted to further refine best practices.
Introduction
Hiatal hernias are a common clinical entity, frequently associated with gastroesophageal reflux disease (GERD) and can significantly impact quality of life (1-3). Symptomatic hiatal hernias, including those complicated by volvulus or aspiration, are clear indications for surgical intervention, as outlined in the American College of Surgeons’ guidance on giant paraesophageal hernia management (4). Minimally invasive techniques, particularly laparoscopic and robotic approaches, have largely replaced open surgery due to lower morbidity, shorter hospital stays, and improved recovery profiles (3,5).
Both laparoscopic and robotic repairs are widely utilized, but the optimal approach remains debated, with institutional and surgeon preferences influencing practice patterns (6-8). The robotic platform offers enhanced visualization, improved dexterity and greater surgeon autonomy, which may be advantageous in complex or re-operative cases. High-level comparative data remain limited and outcomes are generally similar to laparoscopy (6,9,10). Several institutional series and meta-analyses confirm that both approaches are safe and effective, with robotic surgery showing non-inferior short-term outcomes and potential technical benefits, but at higher cost (10-13).
A progressive institutional shift from laparoscopic to robotic hiatal hernia repair (HHR) has been observed in multiple centers, often paralleling increased surgeon experience and institutional investment in robotic platforms (11,13). Retrospective reviews of such transitions provide valuable real-world data supporting the safety and effectiveness of minimally invasive HHR (11,13).
At our institution, a progressive shift from laparoscopic to robotic HHR has occurred over the last several years, coinciding with growing technical proficiency and institutional support. This study presents a retrospective review of our experience with all minimally invasive HHRs—both laparoscopic and robotic—performed by a single surgeon. By analyzing operative characteristics, perioperative outcomes and evolving surgical practices, we aim to contribute real-world data to the growing body of literature supporting the safety and effectiveness of minimally invasive techniques for HHR. We present this article in accordance with the STROBE reporting checklist (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-17/rc).
Methods
We conducted a retrospective, chart-based review of all patients who underwent minimally invasive HHR from February 2018 to February 2024 by a single thoracic surgeon at Mount Sinai Medical Center (MSMC) in Miami Beach, Florida. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Mount Sinai Medical Center (MSMC), and informed consent was waived due to minimal risk to participants (Federalwide Assurance No. FWA00000176).
All adult patients who underwent elective, urgent or emergent minimally invasive HHR during the study period were included. Preoperative cases and those requiring minor concurrent procedures, such as umbilical hernia repair, were also eligible. Patients with diaphragmatic hernias not meeting criteria for hiatal hernia were excluded. These inclusion and exclusion criteria were applied uniformly across both laparoscopic and robotic cases.
Demographic and clinical variables collected included age, sex, ethnicity, BMI, presenting symptoms, preoperative imaging and use of anti-reflux medications. Operative details, including surgical approach, type of crural repair and fundoplication, operative time, intraoperative complications and use of mesh were recorded. Postoperative outcomes included length of stay (LOS), readmission within 30 days, postoperative symptoms, need for endoscopic dilation and symptom resolution at follow-up.
All patients underwent comprehensive preoperative evaluation during their initial clinic visit, including detailed history, physical examination and assessment of functional status and comorbidities. Diagnostic workup included chest and abdominal computed tomography (CT), esophagram and upper endoscopy. Selective Bravo pH monitoring and esophageal manometry were performed in patients with small hernias or significant GERD symptoms. Patients were placed on a liquid diet 48 hours preoperatively and transitioned to clear liquids 24 hours prior to surgery. Bowel preparation with magnesium citrate was administered the day before the operation.
Intraoperatively, a chest X-ray was performed prior to extubation to confirm lung expansion and evaluate for pneumothorax. Decompression endoscopy was routinely performed at the end of the procedure. For emergent, volvulized cases, a nasogastric tube was left in place postoperatively. Patients were kept nil per os (NPO) with IV hydration and pain control. On postoperative day one, all patients underwent a contrast esophagram to assess surgical anatomy and subsequently started on a clear liquid diet and advanced to a full liquid diet the same day. Patients who tolerated oral intake and had no complications were discharged on postoperative day one; most others were discharged by day two.
Patients were followed postoperatively at standardized intervals: 2 weeks, 3 months, and 6 months, primarily through in-person clinic visits. Symptom resolution was assessed based on clinician documentation and patient interviews during follow-up, though no formal symptom scoring tools were utilized. Patients lost to follow-up were documented and excluded from longitudinal outcome analysis.
Statistical analysis
Data were analyzed using Microsoft Excel (Microsoft, Redmond, WA, USA). Continuous variables were summarized as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on distribution, and categorical variables were presented as counts and percentages. Selected outcomes, such as operative time and LOS, were stratified by surgical approach to illustrate institutional trends; however, the study was not powered or designed for formal hypothesis testing between laparoscopic and robotic groups. No multivariable analyses or adjustment for confounders were performed, consistent with the descriptive and observational nature of this study.
The choice between laparoscopic and robotic repair was not randomized and instead reflected the surgeon’s evolving experience and institutional support for robotic surgery. Earlier cases were predominantly laparoscopic, whereas robotic assistance was increasingly utilized in later cases as proficiency with the platform improved. Our operative technique is described in our previous publication (14).
Results
Between 2018 and 2024, a total of 111 patients underwent minimally invasive HHR by a single thoracic surgeon at our institution. The mean age of the cohort was 69 (SD ±14) years, and the mean BMI was 26.6 (SD ±4.6) kg/m2. Ethnically, 53% (n=59) identified as Hispanic, 45% (n=50) as non-Hispanic and 2% (n=2) declined to report ethnicity.
Hiatal hernia types were distributed as follows: Type I (19%, n=21), Type II (18%, n=20), Type III (15.3%, n=17), and Type IV (47.7%, n=53). Preoperative symptoms were diverse and often overlapping. The most common complaints included gastroesophageal reflux (81%, n=90), nausea or emesis (33%, n=37), abdominal pain or discomfort (22%, n=24), respiratory symptoms such as shortness of breath, cough, or aspiration events (28%, n=31) and less frequently, gastrointestinal bleeding (4%, n=4) and volvulus or obstruction (4%, n=4). Anti-reflux medications were used by 90% (n=100) of patients preoperatively. Diagnostic evaluation included esophagogram in 58.6% (n=65), upper endoscopy in 62% (n=69) and manometry in 18% (n=20).
A total of 91 cases (82%) were performed using the robotic platform, while 20 cases (18%) were performed laparoscopically. This distribution reflects a progressive transition toward robotic surgery over the study period, paralleling surgeons growing comfort and access to the robotic platform. Most cases (86%, n=95) were performed electively and 14% (n=16) were urgent procedures.
The overall mean operative time was 194 (SD ±72) minutes. Operative times demonstrated improvement over time, with later robotic cases trending shorter, consistent with the surgeon’s learning curve and increased robotic proficiency. No conversions to open surgery occurred in the entire cohort.
Surgical technique was individualized according to hernia type, intraoperative findings, and patient characteristics. Fundoplication was performed in 60.4% of patients (n=67), including Nissen (30%, n=33), Toupet (22%, n=24), and Dor (9%, n=10) (Figure 1). Gastropexy alone was performed in 38% (n=42), most often in older or higher-risk patients. In two patients with prior partial gastrectomy, neither fundoplication nor gastropexy was feasible due to excessive tension.
Posterior cruroplasty was performed in 34% of patients (n=38), while 66% (n=73) underwent combined anterior and posterior crural closure (Figure 2). In cases with attenuated crural fibers, the repair was reinforced with felt pledgets (Figure 3). Mesh reinforcement was required in only one patient due to a large diaphragmatic defect with loss of domain.
The median hospital LOS was 2 days. A total of 22.5% of patients (n=25) were discharged on postoperative day 1, and 42% (n=47) by day 2. Patients undergoing elective repair were more likely to be discharged within 48 hours. The readmission rate was 10% (n=11), with causes including pulmonary embolism (n=3), intractable abdominal pain (n=2), small bowel obstruction (n=1), pneumonia (n=1), heart failure (n=1), syncope (n=1), intolerance to oral intake (n=1), and slipped fundoplication requiring reoperation (n=1). Postoperative endoscopic dilation was required in 7% of patients (n=7), including one patient who underwent three dilations for a preexisting peptic stricture.
Of the 101 patients with 6-month follow-up, 83% (n=84) reported complete symptom resolution, and an equal proportion (83%, n=84) had discontinued acid-suppressing medications. Persistent postoperative symptoms were reported by 17% of patients, including reflux (n=8), dysphagia (n=3), and nonspecific upper gastrointestinal discomfort (n=6). Ten patients (9%) were lost to follow-up, including two from the laparoscopic cohort and eight from the robotic cohort. Table 1 summarizes demographics, perioperative symptoms, and outcomes.
Table 1
| Variable | Value |
|---|---|
| Total patients | 111 |
| Age (years) | 69±14 |
| BMI, kg/m2 | 26.6±4.6 |
| Ethnicity | |
| Hispanic | 59 (53.2) |
| Non-Hispanic | 50 (45.0) |
| Non-disclosed | 2 (1.8) |
| Hiatal hernia types | |
| Type 1 | 21 (18.9) |
| Type 2 | 20 (18.0) |
| Type 3 | 17 (15.3) |
| Type 4 | 53 (47.7) |
| Preoperative symptoms | |
| Reflux | 90 (81.1) |
| Abdominal pain | 24 (21.6) |
| Nausea/emesis | 37 (33.3) |
| Intolerance to oral intake | 9 (8.1) |
| GI bleeding | 5 (4.4) |
| Volvulus/obstruction | 5 (4.4) |
| Respiratory symptoms | 31 (28.0) |
| Anti-reflux medications used (N=100) (H2 blockers/PPIs) | 90% |
| Preoperative diagnostic tests | |
| Esophagogram | 65 (58.6) |
| Manometry | 20 (18.0) |
| Endoscopy | 69 (62.2) |
| Mean operative time, min | 194±72 |
| Surgical approach | |
| Robotic | 91 (82.0) |
| Laparoscopic | 20 (18.0) |
| Mean operative time by approach, min | |
| Laparoscopic | 288 |
| Robotic | 172 |
| Conversion to open surgery | 0 cases |
| Gastropexy performed | 42 (37.8) |
| Types of fundoplication | |
| Dor | 10 (9.0) |
| Nissen | 33 (29.7) |
| Toupet | 24 (21.6) |
| None | 44 (39.6) |
| Crural closure type | |
| Posterior only | 38 (34.2) |
| Anterior & posterior | 73 (65.8) |
| Mesh reinforcement used | 1 patient |
| LOS, days | 2 [1] |
| LOS distribution | |
| 1 day | 25 (22.5) |
| 2 days | 47 (42.3) |
| 3 days | 16 (14.4) |
| ≥4 days | 23 (20.7) |
| Readmission rate | 11 (9.9) |
| Readmission causes | |
| Abdominal pain | 2 |
| PE | 3 |
| HF | 1 |
| Pneumonia | 1 |
| SBO | 1 |
| Intolerance to oral intake | 1 |
| Slipped wrap | 1 |
| Syncope | 1 |
| Postoperative endoscopic dilation | 8 (7.2) |
| Symptom resolution at 6-month follow-up (of patients not lost to follow-up) | 84 (83.2) |
| Patients lost to follow-up | 10 (9.0) |
| Postoperative symptoms | |
| Reflux | 8 |
| Dysphagia | 3 |
| Vague epigastric pain, and upper gastrointestinal symptoms | 7 |
Data are presented as mean ± standard deviation, number, number (percentage), or median [interquartile range]. BMI, body mass index; GI, gastrointestinal; HF, heart failure; HHR, hiatal hernia repair; LOS, length of stay; PE, pulmonary embolism; PPIs, proton pump inhibitors; SBO, small bowel obstruction.
These findings demonstrate the safety and effectiveness of minimally invasive HHR, with favorable clinical outcomes, low complication rates, and an institutional trend toward robotic surgery over time.
Discussion
This single-institution experience demonstrates that minimally invasive HHR, whether performed laparoscopically or robotically, is a safe and effective strategy with favorable short-term outcomes. Our results are consistent with existing literature indicating that minimally invasive techniques reduce morbidity compared to open surgery, even in the setting of complex or symptomatic hernias (3,5).
The most notable trend in this cohort was the progressive transition from laparoscopic to robotic surgery, reflecting both, institutional and surgeon-level adoption aligned with national practice patterns (11,13). Over the six-year study period, robotic cases increased from a minority to the predominant approach. This shift likely reflects expanding institutional investment in robotic platforms as well as the surgeon’s increasing proficiency with the robotic platform. Although this study was not designed to compare outcomes by operative modality, the observed reduction in operative time across later cases—particularly robotic ones—suggests improved efficiency with greater robotic experience and procedural standardization.
Despite the technical complexity commonly associated with hiatal and giant paraoesophageal hernias (types III and IV comprising over 60% of the cohort), no cases required conversion to open surgery. This underscores the safety and feasibility of minimally invasive repair, even with challenging anatomy. Furthermore, mesh reinforcement was selectively applied to only one patient, yet favorable outcomes were achieved with primary suture repair alone in the vast majority. These findings are consistent with prior reports questioning the routine use of mesh in HHR due to risks of erosion, stricture, or dysphagia (15-18).
Postoperative outcomes were comparable to national benchmarks. The median LOS was 2 days, with nearly two-thirds of patients discharged within 48 hours. Early discharge was especially common following robotic repair, supporting prior observations of enhanced recovery with robotic approaches (19-21). Readmission occurred in 10% of patients, with etiologies including pulmonary embolism, abdominal pain, and gastrointestinal obstruction—all recognized risks following HHR and fundoplication. Importantly, no readmissions were attributable to intraoperative complications, and there were no perioperative mortalities.
Symptom resolution at 6 months was reported by 83% of patients, with an equal proportion discontinuing acid-suppressing medications. These outcomes are comparable to those of large published series and reinforce the therapeutic value of surgical management in patients with refractory GERD or obstructive symptoms (3,22,23). A minority required postoperative endoscopic dilation (7%), and residual symptoms were limited to nonspecific discomfort or dysphagia, consistent with well-described post-fundoplication sequelae (23).
This study has several strengths, including the use of standardized perioperative protocols and the inclusion of all cases performed by a single surgeon, minimizing variability in technique and decision-making. It also captures the real-world evolution of surgical practice, offering insight into institutional adoption of robotic platforms over time. Nevertheless, limitations should be acknowledged. The retrospective design and absence of long-term follow-up limit conclusions regarding recurrence and durability of repair. The lack of standardized symptom assessment tools may underestimate residual symptoms or quality-of-life impact. Additionally, while trends in robotic versus laparoscopic utilization were observed, this was not a randomized comparison and no cost analysis was performed.
Despite these limitations, the findings add to the growing body of evidence supporting the safety, efficiency, and effectiveness of minimally invasive HHR. The observed institutional shift toward robotic repair mirrors national trends and appears associated with improved operative efficiency and earlier discharge, without compromising clinical outcomes.
Conclusions
This single-institution series confirms that minimally invasive HHR is safe and effective, with favorable outcomes across a diverse patient population. High rates of symptom resolution, low complication and readmission rates, and no conversions to open surgery were observed. Although both laparoscopic and robotic techniques were employed during the study period, the results highlight a natural transition toward robotic repair, associated with improved operative efficiency and reduced hospital LOS. These findings support the continued use of individualized, minimally invasive strategies for the management of hiatal hernias and emphasize the growing role of robotic platforms in contemporary foregut surgery.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-17/rc
Data Sharing Statement: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-17/dss
Peer Review File: Available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-17/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoe.amegroups.com/article/view/10.21037/aoe-25-17/coif). F.M.S. serves as an unpaid editorial board member of Annals of Esophagus from August 2024 to December 2026. The other authors have 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Mount Sinai Medical Center (MSMC), and informed consent was waived due to minimal risk to participants (Federalwide Assurance No. FWA00000176).
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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Cite this article as: Alsayegh F, Wahi JE, Kalathoor J, Safdie FM. Minimally invasive hiatal hernia repair: a single-institution experience and evolving surgical trends. Ann Esophagus 2025;8:17.
