***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Objective We recently reported in a multi-institutional , r and omized study of  laparoscopic paraesophageal hernia repair ( LPEHR )  that the anatomic recurrence rate at a median of approximately 5 years was > 50 % . This study focuses exclusively on the symptomatic response to LPEHR and its relationship with the development of a recurrent hernia . Methods During 2002 to 2005 , 108 patients underwent LPHER with or without biologic mesh .  A st and ardized symptom severity question naire , SF-36 health survey , and upper gastrointestinal series were performed at baseline , 6 months , and during 2008–2009 . Results Of 108 patients , 72 ( average age of 68 ± 10 years ) underwent clinical assessment , and 60 of them also had radiologic studies at a median follow-up of 58 ( 40–78 ) months . Radiographic recurrence ( ≥20 mm ) was 14 % at 6 months and 57 % at the time of follow-up , and the average recurrence size was 40 ± 10 mm . All symptoms were significantly improved at long-term follow-up and , with the exception of heartburn , were unaffected by the presence or size of the recurrence . Two patients ( 3 % ) with recurrent symptoms related to their hernia underwent reoperation . Conclusion Despite frequent radiologic recurrences after LPEHR , symptoms remain well controlled , patient satisfaction is high , and the need for reoperation is low Surgery for refractory gastroesophageal reflux disease ( GERD ) and hiatal hernia leads to recurrence or persisting dysphagia in a minority of patients . Redo antireflux surgery in GERD and hiatal hernia is known for higher morbidity and mortality . This study aims to evaluate conventional versus robot-assisted laparoscopic redo antireflux surgery , with the objective to detect possible advantages for the robot-assisted approach . A single institute cohort of 75 patients who underwent either conventional laparoscopic or robot-assisted laparoscopic redo surgery for recurrent GERD or severe dysphagia between 2008 and 2013 were included in the study .  Baseline characteristics , symptoms , medical history , procedural data , hospital stay , complications and outcome were prospect ively gathered . The main indications for redo surgery were dysphagia , pyrosis or a combination of both in combination with a proven anatomic abnormality . The mean time to redo surgery was 1.9 and 2.0 years after primary surgery for the conventional and robot-assisted groups , respectively . The number of conversions was lower in the robot-assisted group compared to conventional laparoscopy ( 1/45 vs. 5/30 , p = 0.035 ) despite a higher proportion of patients with previous surgery by laparotomy ( 9/45 vs. 1/30 , p = 0.038 ) . Median hospital stay was reduced by 1 day ( 3 vs. 4 , p = 0.042 ) . There were no differences in mortality , complications or outcome . Robotic support , when available , can be regarded beneficial in redo surgery for GERD and hiatal hernia . Results of this observational study suggest technical feasibility for minimal-invasive robot-assisted redo surgery after open primary antireflux surgery , a reduced number of conversions and shorter hospital stay Studies reporting on the recurrence rate after laparoscopic repair of large hiatal hernias ( HH ) , including anatomical asymptomatic recurrence , are scarce . This prospect i ve cohort study evaluated the symptomatic and objective outcome of robot-assisted laparoscopic HH repair up to more than 1 year after surgery . A prospect i ve cohort study was performed on 40 consecutive patients with emphasis on operating times , blood loss , intra- and postoperative complications , symptomatic outcome , and anatomical recurrence rate at a minimum of 1 year after surgery . Robot-assisted laparoscopic HH repair proved to be an effective technique with a relatively low mid-term recurrence rate in this prospect i ve series . The operating team experienced the support of the robotic system as beneficial , especially in the dissection of the hernia sac and extensive crural repair Introduction There are numerous reports in the literature documenting high recurrence rates after laparoscopic paraesophageal hernia repair . The purpose of this study was to determine the learning curve for this procedure using the Cumulative Summation ( CUSUM ) technique . Methods Forty-six consecutive patients with paraesophageal hernia were evaluated prospect ively after laparoscopic paraesophageal hernia repair .  Upper GI series was performed 3 months postoperatively to look for recurrence . Patients were stratified based on the surgeon ’s early ( first 20 cases ) and late experience ( > 20 cases ) . The CUSUM method was then used to further analyze the learning curve . Results Nine patients ( 21 % ) had anatomic recurrence . There was a trend toward a higher recurrence rate during the first 20 cases , although this did not achieve statistical significance ( 33 % vs. 13 % , p = 0.10 ) . However , using a CUSUM analysis to plot the learning curve , we found that the recurrence rate diminishes after 18 cases and reaches an acceptable rate after 26 cases . Conclusions Surgeon experience is an important predictor of recurrence after laparoscopic paraesophageal hernia repair . CUSUM analysis revealed there is a significant learning curve to become proficient at this procedure , with approximately 20 cases required before a consistent decrease in hernia recurrence rate is observed Background and Objectives : Computer-assisted robotic surgery allows complex resections and anastomotic reconstructions to be performed with nearly identical st and ards to open surgery . We applied this technology to a variety of pancreatic resections to assess the safety , feasibility , versatility , and reliability of this technology . Methods : A retrospective review of a prospect i ve data base of  robotic pancreatic resections at a single institution between August 2008 and November 2012 was performed . Perioperative outcomes were analyzed . Results : A total of 250 consecutive robotic pancreatic resections were analyzed ; pancreaticoduodenectomy ( 132 ) , distal pancreatectomy ( 83 ) , central pancreatectomy ( 13 ) , pancreatic enucleation ( 10 ) , total pancreatectomy ( 5 ) ,  Appleby resection  ( 4 ) , and Frey procedure  ( 3 ) . Thirty-day and 90-day mortality was 0.8 % and 2.0 % . Rate of Clavien 3 and 4 complications was 14 % and 6 % . The International Study Group on Pancreatic Fistula grade C fistula rate was 4 % . Mean operative time for the 2 most common procedures was 529 ± 103 minutes for pancreaticoduodenectomy and 257 ± 93 minutes for distal pancreatectomy . Continuous improvement in operative times was observed over the course of the experience . Conversion to open procedure was required in 16 patients ( 6 % ) ( 11 with pancreaticoduodenectomy , 2 with distal pancreatectomy , 2 with central pancreatectomy , 1 with total pancreatectomy ) for failure to progress ( 14 ) and bleeding ( 2 ) . Conclusions : This represents to our knowledge the largest series of robotic pancreatic resections . Safety and feasibility metrics including the low incidence of conversion support the robustness of this platform and suggest no unanticipated risks inherent to this new technology . By defining these early outcome metrics , this report begins to establish a framework for comparative effectiveness studies of this platform Background Acute incarceration of paraesophageal hernias ( PEHs ) requiring urgent or emergent surgery is rare . Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions . Our study was design ed to evaluate the feasibility , safety , and efficacy of laparoscopic paraesophageal hernia repair ( LPEHR ) in patients with PEH and acute gastric volvulus . Methods We review ed our prospect ively maintained data base and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012 . Patients were divided into group A ( acute ) , group B ( age- and comorbidity-matched 1:3 ) , and group C ( all elective repairs ) . Group A included those admitted with acute symptoms related to PEH and underwent urgent repair . Patient age , Charlson score , operative time , length of stay ( LOS ) , morbidity , mortality , and recurrence rates were compared . Results Patients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups . The overall mortality rate was low and no statistical difference was found between groups A , B , and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates . Conclusions Historically , patients presenting with acute symptoms related to PEH have required open repair , which is associated with significant morbidity and mortality . The acute group was older and sicker than our elective LPEHR patients and had more adverse events result ing in a longer LOS , even when compared with comorbidity-matched elective patients . However , the LOS remained shorter than that reported for open repair and there was no mortality . The recurrence rates in all groups were low and comparable to elective repairs BACKGROUND This study examines the impact of age and comorbidities on complications and outcomes of  laparoscopic ( Lap ) paraesophageal hernia ( PEH ) repair .  METHODS Data were collected prospect ively on all patients who underwent Lap PEH repair from January 1995 through June 2005 . Pre- and postoperative variables including complications were analyzed . Patients were stratified by age ( Group [ Gr . ] 1 , < 65 years ; Gr . 2 , 65 to 74 years ; Gr . 3 , > /=75 years ) and American Society of Anesthesiology ( ASA ) class ( 1 and 2 vs 3 and 4 ) . Statistical analysis was performed using 1-way ANOVA , chi-square , and Fisher exact test . RESULTS Overall , 171 patients underwent Lap PEH repair . Mean patient age was 65 + /- 15 years , mean ASA class 2.4 + /- 0.5 , gender 72 % female , and mean operating time 173 + /- 49 min . Patients in Gr . 3 had a significantly higher ASA class ( Gr . 1 , 2.3 + /- 0.6 ; Gr . 2 , 2.5 + /- 0.5 ; Gr . 3 , 2.6 + /- 0.5 ) and longer postoperative length of stay ( LOS ) compared with Gr . 1 ( P < 0.05 ) . Esophageal lengthening was required in 10.4 % of patients in Gr . 3 versus 2.6 % in Gr . 1 and 2.1 % in Gr . 2 ( P = 0.079 ) . Total complication rates were 17.1 % in Gr . 1 , 22.4 % in Gr . 2 , and 27.7 % in Gr . 3 ( P = not significant [ NS ] ) . Most complications were minor ; grade 2 or higher complications occurred in 10.5 % of patients in Gr . 1 , 8.3 % in Gr . 2 , and 8.5 % in Gr . 3 ( P = NS ) . There was 1 death ( Gr . 2 ) on postoperative day 18 due to a myocardial infa rct ion ( mortality rate = 0.6 % ) . Mean follow-up was 25.3 + /- 20.6 months . Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use . Anatomic failure of the repair occurred in 23.7 % of patients with adequate follow-up : 26.7 % in Gr . 1 , 15.4 % in Gr . 2 , and 27.8 % in Gr . 3 ( P = NS ) . Reoperation was performed in 1 of 32 ( 3.1 % ) failures . CONCLUSIONS Lap PEH repair is safe in elderly and properly selected high-risk patients , although complication rates are higher than in younger patients . Most patients have a good symptomatic outcome irrespective of their age , but the anatomic recurrence rates remain a concern for all age groups BACKGROUND Laparoscopic surgery is considered the st and ard approach for the treatment of  paraesophageal hernias ( PEHs ) . Despite its advantages , this approach is technically dem and ing with a significant learning curve . Data about the safety and utility of the robotically assisted paraesophageal hernia repair ( RA-PEHR ) are scarce . The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH . MATERIAL S AND METHODS Between June 2010 and December 2015 , patients who underwent elective RA-PEHR were included in a prospect ively collected data base . Demographic data , American Society of Anesthesiologists ( ASA ) classification , preoperative testing , operative time ( OT ) , length of hospital stay ( LOS ) , conversion rate , morbidity , and mortality were recorded and review ed retrospectively . RESULTS Sixty-one patients underwent RA-PEHR with mesh , 72 % were female ( mean age of 63 and mean body mass index [ BMI ] of 30 ) . ASA classification was 2.6 ( 57 % of patients had an ASA III ) . With respect to the type of the hernia , the preoperative diagnosis was : Type II 26 % , III 64 % , and IV 13 
    Output:
    
Robotic Paraesophageal repair is a safe ( similar rate of complication and mortality to literature for laparoscopic procedure ) and an effective ( paraeshopageal hernia repaired without high recurrence ) procedure with acceptable complication rates even in older patients with high operative risks