Introduction: Giant hiatal hernia is a challenging problem for its difficult surgical management. To achieve a complete reduction of the hernia’s sac without compromise surrounding structures, the extraperitoneal approach is generally preferred. Hiatal hernia is often associated with obesity due to the augmented pressure on the esophagogastric junction and the diaphragm. Its incidence is about 40% in population with obesity, compared to a 22.6% in general population. In cases of obese patients with symptomatic hiatal hernia, the best surgical approach is hernia repair with concomitant Roux-en-Y gastric bypass (RYGBP). The use of a robotic platform is particularly beneficial in complex cases due to its enhanced visualization and precision.

Case report: A 56-year-old female with a history major depressive disorder, bile acid malabsorption, and a previous laparoscopic cholecystectomy with a maximum body mass index (BMI) of 39.5 kg/m² was admitted in emergency room for presenting epigastric pain and poor oral tolerance. Complementary tests, including an upper gastrointestinal series, esophagogastroduodenoscopy, and pHmetry, confirmed a 9 cm hiatal hernia with a DeMeester score of 45. Complete patients’ preoperative evaluation is mandatory to plan the correct surgery for both obesity and hernia repair. In this case RYGBP was selected due to preoperative study results and patients’ symptomatology. Surgery was performed using robotic-assisted setting with the DaVinci Xi platform. Four 8 mm robotic trocars and one 12 mm assistant port were placed. To obtain a safe liberation and reduction of intrathoracic hernia’s sac, an extraperitoneal approach was used. Diaphragmatic pillars were closed with a continued barbed suture. RYGBP was choose as bariatric technique to treat patients’ obesity. Both biliopancreatic limb and alimentary limb were 100 cm long. Mesenteric and Petersen defects were closed using unabsorbable barbed sutures. Operative time was 120 minutes without any intraoperative complications. Patient had uneventful postoperative course and was discharge on the second postoperative day. At three months post-surgery, the patient showed no symptoms of reflux nor pain or dysphagia and achieved a BMI of 33.6 Kg/m².

Discussion: Robotic surgery provides a minimally invasive approach for complex cases involving hiatal hernia repair. The extraperitoneal technique facilitates safe and complete hernia reduction, while the robotic system provides enhanced visualization and precision, crucial in difficult cases.