Robotic Paraesophageal Hernia Repair with Magnetic Sphincter Augmentation Using the LINX Device

Case Overview

Paraesophageal hernias (PEH) are a complex subset of hiatal hernias. For a Type III paraesophageal hernia, both the gastroesophageal junction (GEJ) and the fundus of the stomach migrate through the diaphragmatic hiatus and into the thoracic cavity. The condition affects approximately 5% of all hiatal hernia cases, predominantly occurring in women.^1,2,3

The pathophysiology of paraesophageal hernias is complex. The primary anatomical defect involves a weakening of the phrenoesophageal membrane and enlargement of the diaphragmatic hiatus, often accompanied by elongation of the gastric ligaments. This anatomical disruption can lead to a variety of complications, including mechanical obstruction, volvulus, ischemia, and bleeding from ulcers.^4,5

Up to a degree, the size of a hiatal hernia is not as important as the symptoms it causes. Gastroesophageal reflux disease (GERD) frequently coexists with paraesophageal hernias, affecting more than half of the patients.⁶ This association is attributed to the disruption of normal anatomical barriers against reflux, including the diaphragmatic crura, the acute angle of His, the lower esophageal sphincter longitudinal and circular fibers, as well as the collar sling fibers of the stomach. As the stomach moves through a weakened diaphragmatic hiatus, the natural mechanisms against reflux are disrupted. This leads to easy reflux of gastric contents due to loss of the barrier function of the hiatus and GEJ. The presence of GERD significantly influences the surgical approach, as both the anatomical defect and reflux mechanism must be addressed to achieve optimal outcomes. However, once the stomach has moved enough through the hiatus, sometimes the size itself is enough to dictate surgical repair.

The surgical management of paraesophageal hernias has evolved substantially over the past decades. The shift from open surgery to minimally-invasive techniques marked a significant advancement, with laparoscopic repair becoming the standard of care in the 1990s.^7–9 The introduction of robotic surgical systems in the early 2000s further refined the technical aspects of the procedure, offering enhanced visualization and improved instrument articulation in the confined space of the mediastinum.

Traditional anti-reflux procedures, particularly fundoplication, have been the mainstay of surgical GERD management in the context of hiatal hernia repair. While 50–70% of the anti-reflux mechanism is re-established by performing a full mediastinal dissection and hiatal hernia repair, the remaining 30–50% depends on the function of the now-ineffective lower esophageal sphincter (LES). Therefore, the LES must be restored to complete the anti-reflux barrier. Traditionally, fundoplication is performed to reapproximate or augment the LES and re-establish the remaining anti-reflux mechanism.

Various approaches to fundoplication exist, each with specific merits and challenges. Overall, there is a delicate balance between dysphagia and persistent or recurrent GERD, and the extent of the wrap typically dictates postoperative outcomes. The gold standard fundoplication has been the 360-degree Nissen fundoplication, first performed in 1956 and laparoscopically in 1991. However, there is up to a 60% incidence of postoperative gas bloat and dysphagia, prompting concerns regarding its side-effect profile for routine use.

Alternative types of fundoplication employ a lesser degree of wrap. Among these, the Toupet fundoplication, a posterior 270-degree wrap leaving a portion of the anterior esophagus exposed, is becoming increasingly utilized. The rationale behind the Toupet approach is that it may offer comparable anti-reflux properties while minimizing the risk of dysphagia or gas bloat by allowing venting of the stomach—a benefit not provided by the Nissen procedure. However, this remains controversial, as current data do not conclusively establish superiority for either technique.^10–14

In the first six months postoperatively, dysphagia appears significantly reduced in patients undergoing Toupet fundoplication compared to those receiving a Nissen fundoplication. Between six months and two years, no substantial difference in dysphagia or GERD symptoms has been observed between these two techniques. However, after two years, some meta-analyses have reported increased clinical and subclinical GERD in the Toupet population, although dysphagia and reoperation rates remain comparable. Another recent meta-analysis indicates a slight trend favoring Toupet fundoplication, but the evidence remains insufficient to recommend a singular approach conclusively. Additionally, this meta-analysis failed to demonstrate a significant reduction in gas bloat or dysphagia with Toupet wraps, suggesting that individual surgeon nuances likely influence outcomes.

Some data even suggest that for large paraesophageal hernias, fundoplication may not significantly improve symptoms or recurrence rates compared to reduction alone with or without gastropexy. Consequently, our preference is to tailor the surgical approach to individual patient factors, such as specific symptoms, tolerance for potential side effects, presence of Barrett’s esophagus (favoring a complete wrap to potentially prevent progression), and hernia size, all contributing to the overall outcome.¹⁹

Given the controversy surrounding the optimal fundoplication type and technique, there has been a desire to standardize procedures to minimize GERD symptoms. This led to the introduction of the LINX device (Ethicon, Johnson and Johnson, Cincinnati, OH) in Europe in 2007 and subsequently in the US in 2012, providing a novel alternative for reflux control.¹⁵ The LINX system consists of interlinked titanium beads with magnetic cores designed to augment LES function while allowing physiologic reflux mechanisms to remain intact.

The robotic approach to paraesophageal hernia repair with concurrent LINX placement represents a convergence of these technological advancements. Robotic systems offer several distinct advantages over traditional laparoscopy. The three-dimensional, high-definition visualization improves identification of anatomical planes and critical structures, especially during mediastinal dissection. Articulating instruments facilitate complex maneuvers in confined spaces, notably during crural closure and device placement. Additionally, tremor filtration and motion scaling enhance the surgeon’s technical capability, potentially improving tissue handling precision and suture placement.^16,17 However, this manuscript does not claim superiority over traditional laparoscopic approaches; rather, it aims to highlight specific advantages provided by robotic-assisted laparoscopy.

Therefore, this combined approach also presents unique challenges. The procedure requires specific expertise in both robotic surgery and LINX device placement. Patient selection becomes particularly critical, as both the anatomical characteristics of the hernia and the physiological parameters of the esophagus must be carefully evaluated. Contraindications to LINX placement, such as motility disorders or the need for future magnetic resonance imaging, must be carefully considered, even in the presence of an otherwise repairable hernia. High-resolution manometry is crucial for excluding motility disorders that contraindicate LINX placement. Upper endoscopy with careful biopsy of the GEJ provides direct mucosal evaluation, confirming the absence of Barrett's esophagus or other concerning findings.

Cost considerations also play a significant role in the implementation of this technique. The combined cost of robotic technology and the LINX device can impact healthcare economics and access to care. There is added cost with each LINX device, but the surgical time is often shorter and the patients leave the same day.  Therefore, potential benefits with reduced complications and improved outcomes may offset these initial costs, though long-term data continues to emerge.¹⁸

The patient shown in this video had a 5-cm paraesophageal hernia with 20 years of classic heartburn symptoms which had become refractory to BID PPI and H₂ blocker. A Gastroscopy was performed with cold forceps biopsies and Wide Angle Transepithelial Sampling (WATS) biopsies, showing no Barrett’s Esophagus or esophageal adenocarcinoma. An esophagram was performed with normal gross motility, followed by High Resolution Manometry showing a normal IRP and 100% normalesophageal motility. A discussion with the patient then occurred, describing a hiatal hernia with both fundoplication (Nissen vs Toupet) and a magnetic sphincter augmentation (LINX). The risks and benefits of both procedures were discussed, and this patient decided that the benefits of a LINX were higher than with a fundoplication.

This video provides a step-by-step detailed explanation of the robotic paraesophageal hernia repair with concurrent LINX placement, demonstrating the technical nuances of this complex procedure as described below.
The procedure is performed under general anesthesia with endotracheal intubation. The patient is positioned supine with arms tucked and legs separated in the modified lithotomy position: the hips are elevated 10–15 degrees, and the knees are flexed 10–15 degrees, which raises the lower extremities only slightly above the body. After appropriate padding and securing, the patient is placed in the reverse Trendelenburg position at approximately 15–20 degrees. The robotic system is docked over the patient's head at a 30-degree angle to optimize workspace geometry.

This author prefers initial access through a modified Veress technique with entry lateral to Palmer's point. After establishing pneumoperitoneum at 15 mmHg, four 8-millimeter robotic ports are placed in a curvilinear fashion across the upper abdomen. Port positioning is critical, ensuring adequate spacing (minimum 6–8 cm) to prevent instrument collision. A separate subxiphoid port is also placed for a Nathanson liver retractor to facilitate liver retraction.

The operation begins with the division of the gastrohepatic ligament, providing access to the right crus. Careful dissection through the avascular plane between the right crus and esophagus is performed, with attention to preserving the anterior and posterior vagal trunks. The dissection proceeds circumferentially around the esophagus, extending superiorly into the mediastinum. A complete mediastinal dissection is essential to achieve an intra-abdominal esophageal length of 3–4 cm, extending to the level of the inferior pulmonary veins or higher. The peritoneal lining of the crura is carefully preserved when possible to maintain tissue strength for subsequent repair.

Following complete mobilization, the hernia contents are naturally reduced into the abdomen. The crural defect is closed posteriorly using interrupted permanent braided sutures, incorporating substantial bites of the crural muscle while avoiding injury to the underlying aorta or adjacent structures. The repair is typically completed with 3–4 sutures, creating a secure but not tight closure around the esophagus.

A critical step for the LINX placement involves creating a window between the esophagus and posterior Vagus nerve for device placement. This allows a place for the LINX device to sit and prevents migration onto the stomach. The sizing procedure is performed using a sizing tool placed through one of the ports, which has a flexible magnet that closes around itself to ensure proper sizing. It is important to position the most lateral-right port so that the sizing device encounters the esophagus at a 90 degree angle. This will allow the most appropriate sizing without needing to manipulate and distort the esophagus. The appropriate size will show rotation of the sizing device around itself when moved, no compression of the esophagus, no large space between the esophagus and the device, and typically three sizes larger than the point at which the sizing tool pops off itself. The ideal LINX device will lay more like a necklace around the esophagus, and not tight like a choker. Once the size is chosen, the appropriate LINX device is introduced through an 8-mm port and positioned around the esophagus, ensuring proper orientation and engagement of the clasping mechanism.

Endoscopy is performed to confirm the appropriate device position, visualizing the separation of magnetic beads during scope passage. The liver retractor is removed, and all port sites are inspected for hemostasis. Given the 8-mm port size, fascial closure is typically not required unless port site enlargement occurs during the procedure.

The postoperative protocol is designed to promote proper device function and tissue healing. Patients are able to start on a regular diet right away, and are discharged the same day of surgery. A structured diet is essential, with patients instructed to consume small amounts of solid food hourly while awake during the first two weeks post-surgery. This regimen promotes the formation of elastic scar tissue around the device beads, which is crucial for optimal function.

Robotic paraesophageal hernia repair with concurrent LINX device placement represents an evolutionary step in the surgical management of complex hiatal pathology. When performed with appropriate patient selection and attention to technical detail, the procedure offers excellent outcomes with acceptable morbidity. This instructional video will be particularly beneficial for surgeons, surgical trainees, and advanced practice providers seeking to enhance their understanding of the technical aspects of robotic paraesophageal hernia repair with LINX placement, as well as for medical educators teaching complex, minimally-invasive upper gastrointestinal procedures.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.