OA06-LBA01.7. Robotic Preservation of the Anterior Sac Suturing (PASS) Technique for GERD: Anatomical Rationale, Surgical Technique and Early Outcomes

Abstract

Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Hiatal hernia recurrence remains a major limitation of antireflux surgery, frequently originating at the anterior–lateral hiatus. Preservation of native anatomical structures may improve durability of repair. We describe the Robotic Preservation of Anterior Sac Suturing (PASS) technique and evaluate its anatomical rationale, feasibility, and early clinical outcomes. Methods A retrospective analysis was performed of patients undergoing robotic surgery for gastroesophageal reflux disease (GERD) between February 2025 and January 2026. Inclusion criteria comprised erosive esophagitis grade B or higher, pathological 24-hour esophageal pH monitoring (DeMeester score >14.5), hiatal hernia ≥2 cm, or recurrent hiatal hernia. All patients underwent the PASS technique combined with posterior hiatoplasty and systematic gastropexy, with either total or partial fundoplication based on esophageal motility. Selected cases received absorbable mesh reinforcement. Postoperative follow-up at 1, 3, and 6 months assessed dysphagia, gas-bloat syndrome, flatulence, and reflux symptoms. Operative console time, complications, hospital stay, and dietary progression were recorded. Anatomical assessment was performed by thoracic computed tomography or upper endoscopy in selected patients. Quality of life was evaluated using the SF-36 questionnaire preoperatively and postoperatively. Results Among approximately 100 robotic procedures performed during the study period, 52 patients met inclusion criteria. Mean age was 65 years (range 37–88), with 29 females; 21% were older than 75 years. Heartburn and regurgitation were the predominant symptoms. Preoperative evaluation included esophageal manometry in all patients, esophagography in 38%, and thoracic computed tomography in 71%. Surgical procedures consisted of Nissen fundoplication in 35%, Toupet fundoplication in 52%, and Roux-en-Y gastric bypass in 13% (BMI >30 kg/m.). Absorbable mesh was used in 18 cases. Mean robotic console time was 117 minutes (60–261). No postoperative dysphagia, gas-bloat syndrome, major complications, or transfusions occurred. One wrap migration was observed in a patient not treated with PASS. Mean hospital stay was 36 hours. Significant improvement in SF-36 scores was observed, particularly in patients older than 75 years. Conclusion The PASS technique is a safe and reproducible robotic approach with excellent early outcomes. By preserving the anterior and left-lateral hiatal anatomy—common sites of recurrence—this technique addresses a critical anatomical weakness in conventional repairs. These preliminary results suggest a potential paradigm shift in hiatal hernia surgery. Longer follow-up and prospective randomized trials are warranted to confirm its durability and long-term clinical benefits.