Robot-Assisted Laparoscopic Repair of a Paraesophageal Hernia During the 3rd Trimester of Pregnancy

Abstract

Background: New hiatal hernia diagnosis in pregnancy is rare. Type IV hernias comprise less than 5% of those diagnosed and have been historically managed non-operatively or by laparoscopic exploration. Previously described outcomes include significant maternal and perinatal morbidity and mortality. Minimal literature exists on the outcomes of robot-assisted laparoscopic surgery during pregnancy for any indication due to the rarity of these cases. We present a case of a type IV hernia diagnosed in the third trimester repaired via robot-assisted laparoscopy with minimal peri/postoperative maternal or fetal complications. Case Description: A 29-year-old primigravida with prior sleeve gastrectomy presented at 27+6 weeks gestation with acute left upper quadrant abdominal pain, nausea, and vomiting. Computed tomography scan showed a type IV paraesophageal hernia containing stomach, small bowel, and colon; surgical repair was advised. She was counseled on the fetal risks of non-obstetric surgery, and the maternal-fetal medicine team recommended antenatal corticosteroids, pre/postoperative non-stress test (NST), left tilt of the hips intraoperatively, indomethacin for tocolysis, and mechanical and pharmacologic deep vein thrombosis prophylaxis. A robot-assisted laparoscopic hernia repair with mesh was performed with subcostal margin port placement to avoid the gravid uterus. Surgery was complicated by a left capnothorax requiring decompression. Postoperative NST was reassuring, postoperative milestones were met, and discharge occurred on postoperative day 2. Subsequent pregnancy course was uneventful. Labor was induced at 37+0 weeks gestation due to gestational hypertension, and uncomplicated vaginal delivery occurred the next day with discharge on postpartum day 1. Clinical Significance: This case contributes to the limited reported outcomes on this rare diagnosis and uncommon surgical approach in the third trimester. Conclusion: Robot-assisted surgical repair of paraesophageal hernias may be successfully performed in the third trimester.