39 Robotic Repair of Recurrent Giant Hiatal Hernia and Excision of Sarcoma.

Abstract We present a case of a recurrent giant hiatal hernia in a 72-year-old patient with a history of transthoracic hiatal hernia repair performed decades prior. The patient was referred with progressive epigastric pain and difficulty swallowing. Imaging confirmed a large intrathoracic stomach with an incidental hiatal sarcoma on the left crura of the diaphragm. A robotic-assisted repair was undertaken to address the complex anatomy and anticipated adhesions. Intraoperatively, dense adhesions and significant herniation of the stomach into the thoracic cavity were encountered. The hiatus was reduced and posteriorly repaired. A decision was made not to perform a fundoplication. Instead, an anterior gastropexy was performed to reduce the risk of recurrence. The surgical video highlights key operative steps, including safe dissection, crural closure, and gastropexy technique, as well as technical challenges associated with prior surgery and altered anatomy. The patient initially recovered well but re-presented postoperatively with progressive dysphagia and retching. Imaging suggested no obvious obstruction. An emergency laparoscopic was performed and revision was performed to release the gastropexy and restore gastric anatomy. The patient subsequently recovered fully, with resolution of symptoms and return to normal diet. This case illustrates the complexity of recurrent giant hiatal hernia repair, particularly in patients with prior thoracic surgery. It highlights the value of robotic assistance in complex preoperative foregut surgery and highlights the importance of individualized operative planning.