A minimally invasive approach is the most common technique for hiatal hernia repair. The robotic platform offers a unique advantage that addresses the limitations of a laparoscopic repair. The steps of a robotic hiatal hernia repair include reduction of hernia contents, dissection of hernia sac, circumferential dissection of esophagus with 2.5 to 3 cm of intraabdominal esophagus, crural closure, and partial or complete fundoplication. The robotic hiatal hernia repair has comparable perioperative outcomes to the laparoscopic approach. This article discusses current controversies, limitations, and new technologies.

Gastrointestinal stromal tumors (GISTs) are sarcomas that arise from the muscular layer of the gastrointestinal tract. The stomach is the most common location, followed by the small intestine. Surgical resection is the cornerstone of treatment; extensive margins and lymphadenectomy are not routinely required. Commonly utilized resection techniques include wedge gastrectomy, excision and closure of the gastrotomy, and anterior gastrotomy access with internal wedge resection. Tyrosine kinase inhibitors can be utilized in the neoadjuvant setting for cases where a reduction in tumor size would optimize resection, and in the adjuvant setting for high-risk tumors. In select cases, metastasectomy may improve prognosis.

The surgical management of gastric cancer has changed significantly from the first open partial gastrectomy in 1881 to contemporary minimally invasive approaches. The approach has shifted from open surgeries to laparoscopic and robotic-assisted gastrectomies, with evidence of reduced pain, quicker recovery, and lower morbidity with these methods. Multiple randomized trials have confirmed that laparoscopic surgeries yield oncologically safe results. Moreover, robotic surgeries, while more expensive, provide similar outcomes with some procedural benefits. Herein, we discuss surgical techniques, preoperative planning, and postprocedure care, emphasizing the role of careful clinical assessment and tailored surgical approaches based on tumor location and patient condition.

Achalasia is an incurable condition of the esophagus involving the inflammation and degeneration of inhibitory neurons of the lower esophageal sphincter (LES) resulting in failure of the LES to relax. Typical symptoms of achalasia are dysphagia, retrosternal chest pain, regurgitation, and weight loss. Three studies are typically required for the diagnosis of achalasia: barium swallow, high-resolution esophageal manometry, and esophagogastroduodenoscopy. Differential diagnosis includes gastroesophageal reflux disease, pseudoachalasia, neoplasm, and nonachalasia esophageal motility disorders such as scleroderma, jackhammer esophagus, distal esophageal spasm, and nutcracker esophagus.

Medical advancements, including Helicobacter pylori eradication and antisecretory agents, have reduced peptic ulcer disease (PUD)-associated hospital admissions, mortality, and surgical interventions over the past 30 years. Surgery plays an important role in the treatment of life-threatening complications of PUD, such as bleeding, perforation, and gastric outlet obstruction, as well as for disease that is refractory to medical management. The article highlights the critical role of surgery in cases where medical therapy is insufficient or in the event of emergency complications arising from PUD.

Surgical management of gastric cancer has evolved over the years. Incorporation of minimally invasive techniques has led to shorter hospital stays, reduced wound complications, and earlier return to functional activity. Nevertheless, the development of minimally invasive total gastrectomy as a repertoire in the management of proximal or diffuse gastric cancer requires significant commitment and support owing to the complexity of the procedure. Here the authors describe the evolution of total gastrectomy with particular focus on laparoscopic and robotic approaches. In addition, they outline the data comparing minimally invasive total gastrectomy with traditional open surgical approaches.

Gastric perforation is a core emergency disease treated by the general surgeon. The majority are caused by peptic ulcer disease and neoplasms; however, other etiologies, such as iatrogenic injury and gastric ischemia, are prevalent enough to merit separate attention. While the authors can extrapolate from our knowledge of the treatment of ulcer and neoplastic perforations when treating the lesser known causes, there are nuanced differences in how they approach it. The recognition and treatment of non-ulcer, nonneoplasm gastric perforation will be the focus of this article.

Gastric cancer is a highly prevalent malignancy in Asia; however, its incidence is rising in the United States. Traditionally, methods of treatment include surgery and chemotherapy. Endoscopy has become an alternative method with a low recurrence rate when used to treat early gastric cancers. Endoscopic mucosal resection and endoscopic submucosal dissection are the 2 mainstay methods of endoscopy treatment. They are advantageous compared to surgery as they are less invasive and maintain anatomic integrity for the patient. However, lesion selection is crucial for success. In this article, the authors describe the 2 methods in detail in the treatment of early gastric cancers.

Current treatment for gastric cancer includes a multidisciplinary approach of systemic therapy and surgery. While retrospective, prospective, and randomized trials have demonstrated conflicting results on the need for extended lymphadenectomy, current guidelines dictate a recommendation for the retrieval of at least 16 lymph nodes to accurately stage patients. The "D1" lymph nodes along the major gastric and epiploic vessels may provide adequate lymph node harvest, though "D2" lymphadenectomy along the celiac axis and its branches may be necessary. Performing a distal pancreatectomy and splenectomy to maximize the D2 nodal harvest is not necessary and leads to increased morbidity.

Gastric cancer remains one of the most common causes of cancer death worldwide. Endoscopic ultrasound (EUS) plays a key role in the diagnosis and staging of gastric cancer. EUS can allow for in-depth cancer staging by detailing tumor size, depth of invasion in the gastric wall, presence of metastatic lymphadenopathy, and detection of liver metastases. EUS can also help distinguish among a variety of subepithelial gastric mass lesions, many of which are neoplastic. These factors help guide decision management in terms of appropriateness for endoscopic or surgical resection and overall management strategy for patients.

Gastric cancer is prevalent worldwide and is a leading cause of cancer-related death. Patients with GC often present at advanced stages at diagnosis. Patients with locally advanced diseases experience poor survival rates with surgery alone. Multimodality therapy, including peri-operative therapy and adjuvant therapy, has improved outcomes. However, there is no consensus on the optimal treatment approach. Molecular characteristics of GC may help guide treatment choices and studies are currently underway to evaluate other treatment modalities including immunotherapy and targeted therapy.

Patients with gastric cancer peritoneal metastases (GCPM) have Stage IV disease. Systemic therapy is a crucial aspect of their care. Patients with GCPM should have their tumors tested for HER2 and PD-L1 expression and microsatellite instability for potential targeted therapies. If patients with synchronous GCPM have stable disease following neoadjuvant therapy, surgical intervention can be considered. Patients with positive cytology or low-volume peritoneal disease (peritoneal carcinomatosis index [PCI] < 7) may "convert" to negative cytology or resolution of peritoneal metastases following intraperitoneal therapy and may be candidates for subsequent gastrectomy.

Gastric cancer is a leading cause of cancer and cancer-related mortality worldwide, especially in East Asia. It is often diagnosed at an advanced stage, which carries a poor prognosis. Patients with advanced gastric cancer typically receive systemic therapy and best supportive care. For patients with locally advanced gastric cancer, a combination of systemic therapy and surgical resection is recommended, while surgical resection-alone is recommended for patients with early-stage localized tumors. Surgical resection, including total gastrectomy, distal gastrectomy, and proximal gastrectomy, is recommended for resection of localized tumors based on tumor location. Herein, the authors provide an overview of open gastrectomy resection and reconstruction techniques.

The obesity epidemic poses a significant global health challenge. Despite proven efficacy, accessibility to bariatric surgery is limited. Endoscopic bariatric therapies offer less invasive alternatives. Reversible space-occupying devices like intragastric balloons are suitable for both primary obesity treatment and bridging to surgery. Restrictive therapies that reduce gastric volume like the primary obesity surgery endoluminal and endoscopic sleeve gastroplasty have shown promising short-term results. Diverting devices such as intestinal liners/barriers or magnet-assisted anastomoses aim to replicate surgical effects with lower risks, though efficacy varies. Finally, endoscopic revisional procedures like transoral outlet reduction address weight regain post-bariatric surgery.

Gallbladder cancer is the most common biliary tract malignancy, often detected incidentally post-cholecystectomy or at an advanced stage, historically linked to a poor prognosis. Advances in minimally invasive surgery and systemic therapies have improved outcomes. Global incidence varies, with risk factors including gender, age, gallbladder disease history, and polyp size influencing malignancy risks. Management involves cross-sectional imaging, staging laparoscopy in select cases, and radical cholecystectomy with lymphadenectomy and adjuvant therapy, though its use is limited. Trials are ongoing assessing the role of neoadjuvant therapy. Prognosis depends on the tumor stage, with early detection crucial for long-term survival.

Management of intrahepatic cholangiocarcinoma relies on a thorough understanding of the tumor's location and proximity to critical vasculobiliary structures. Mid-common bile duct tumors may require hemihepatectomy or pancreatoduodenectomy based on the status of the intraoperative frozen section. Distal common bile tumors are treated with pancreatoduodenectomy. When appropriate, volumetric assessment of the remnant liver should be performed to identify cases requiring preoperative liver augmentation strategies. A similar strategy should be employed for perihilar tumors, which require a right trisegmentectomy with bilioenteric reconstruction to achieve a negative margin. Adjuvant systemic therapy is recommended and increasing usage of neoadjuvant treatment is being incorporated into borderline resectable or regionally advanced cases.

Biliary malignancy is rare, often carries poor prognosis, and most patients are not resection candidates at diagnosis. There are a variety of endoscopic, percutaneous, and systemic treatments that are used to address the symptoms and complications of biliary malignancy. Additionally, best supportive care and palliative care should be incorporated into care plans early on in a patient's course. It is important for all physicians to be equipped to have conversations regarding overall prognosis, general expectations, and goals of care to determine a care plan individualized for each patient.