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Mesh in laparoscopic large hiatal hernia repair: A systematic review of the literature
Abstract
The use of mesh is becoming more popular for large hiatal hernia (type II-IV) repair to reduce the recurrence rate. The aim of this study was to outline the currently available literature on the use of mesh in laparoscopic large hiatal hernia repair, emphasizing objective outcome.
A structured search of the literature was performed in the Medline, Embase, and Cochrane Central Register of Controlled Trials databases.
A total of 26 studies met the inclusion criteria. There were three randomized controlled trials, seven prospective and five retrospective cohort studies, and five prospective and one retrospective case-control study. The study design was not reported in the remaining studies. In the included studies, laparoscopic hiatal hernia repair was performed with mesh in 924 patients (mesh group) and without mesh in 340 patients (nonmesh group). The type of mesh used was very different: polypropylene in six, biomesh in nine, polytetrafluoroethylene (PTFE) in two, expanded PTFE (ePTFE) in two, and composite polypropylene-PTFE in another two. At least two different kinds of mesh were used in five studies. Radiological and/or endoscopic follow-up was performed after a mean (±SEM) period of 25.2 ± 4.0 months. There was no or only a small recurrence (recurrent hiatal hernia <2 cm) in 385 of the 451 available patients (85.4 %) in the mesh group and in 182 of 247 (73.7 %) in the nonmesh group.
The use of mesh in the repair of large hiatal hernias is promising with respect to the reduction of anatomical recurrences. However, many different kinds and configurations of mesh are available. This systematic review of the literature is a basis for high-quality randomized controlled trials to obtain the most effective and safe mesh in the long term.
... The use of prosthetic mesh to augment suture repair of large paraoesophageal hernias is widespread but controversial. Several meta-analyses have demonstrated that crural reinforcement with non-absorbable mesh increases the durability of repair of a large hiatus hernia [1][2][3][4][5]. More recent metaanalyses that include randomised controlled trials only have shown no durability benefit when TiMesh is used [6][7][8]. ...
... The advantage of prosthetic mesh in preventing hiatal hernia recurrence is not conclusively established. Five meta-analyses examining mesh-reinforced hiatal repair versus suture-only repair demonstrated a lower recurrence rate in patients undergoing a non-resorbable mesh-reinforced repair at shortto medium-term follow up [1][2][3][4][5]. However, more recent meta-analyses involving randomised controlled trials have not shown this benefit [6][7][8]. ...
... The authors recognise this should be taken only as an estimate of realworld results as the respondents' data could not be verified, but it does appear to align with other reports of mesh complications. A systematic review of the literature calculated the incidence of oesophageal erosion and dense fibrosis causing oesophageal stenosis as 0.2% and 0.5%, respectively [2]. ...
The use of prosthetic mesh to augment suture repair of large paraoesophageal hernias is widespread but controversial. Our aim was to identify the risk of mesh-specific complications from a large series of consecutive patients undergoing hiatal hernia repair augmented with a lightweight polypropylene mesh (TiMesh) over a 12-year period. A case series review of patients who have had prosthesis-reinforced hiatal repair with TiMesh between February 2005 and October 2017. Pre-operative, intra-operative, and post-operative data were collected for all patients undergoing hiatal repair. In total, 393 patients had TiMesh augmented hiatal repair between February 2005 and October 2017. There were no intraoperative mesh-specific complications. Mesh was explanted in one patient (1/393, 0.25%) who underwent emergency paraoesophageal hernia repair complicated by sepsis. Asymptomatic mesh erosion was found in two patients (2/393, 0.51%) at endoscopy 3 and 9 years following surgery, respectively. No cases of oesophageal or hiatal strictures were identified. From our large series, albeit without routine endoscopic and radiological follow-up, we demonstrate acceptably low rates of mesh-related complications. We identified two cases of asymptomatic erosion during 393 TiMesh repairs, and the rate of mesh-specific complications in this patient series is low. This unit will continue to perform selective TiMesh hiatal repair in cases where a suture repair only is felt to be inadequate at the time of surgery. For the purposes of patient consent and ongoing discussion, we report the risk of mesh erosion and mesh explantation to be 0.51% and 0.25%, respectively.
... Many recurrences are asymptomatic. Radiological outcome is less favorable, and radiological recurrences are reported in more than 50% of patients, most are asymptomatic (1,4). ...
... As such, prosthetic mesh use remains controversial, especially due to potential mesh-related complications, such as infection, local inflammation, fibrosis, mesh migration and shrinkage, esophageal or gastric erosion, hiatus and esophageal stenosis and obstruction, fistula formation and dysphagia (4,5). Also, mesh use poses itself additional difficulties in cases in which surgical reintervention in needed, and operations performed to solve mesh-related complications are associated with higher morbidity and mortality rates (1,5). There are different types of mesh, synthetic, including heavy and light-weight polypropylene, expanded polytetrafluoroethylene (ePTFE), and biologic. ...
... Suturing a horseshoe-shaped mesh as an on-lay to crura repair, leaving a small gap between the mesh and the esophagus to avoid erosion and circumferential contraction. Indications for mesh use in laparoscopic repair varies, and there is still insufficient evidence to recommend it as a standard (1,4). Further standardization of procedures and increased numbers in case series are required for drawing definitive conclusions regarding mesh reinforcement in GHH repair. ...
... Грыжи пищеводного отверстия диафрагмы (хиатальные грыжи) являются одним из наиболее распространенных вариантов нарушения висцеральной анатомии. Данное состояние характеризуется смещением любых органов брюшной полости, кроме пищевода, в грудную полость [1][2][3]. ...
... Определенную роль может играть ослабление связочного аппарата желудка или других органов. Этими механизмами объясняется рост распространенности грыж пищеводного отверстия диафрагмы с возрастом [1,3,4]. ...
... Для параэзофагеальных грыж характерно естественное положение желудочно-пищеводного перехода, в то время как часть желудка через пищеводное отверстие диафрагмы смещается в средостение [2,3,6,8]. ...
The article presents modern ideas of types II–IV hiatal hernias as a variant of visceral anatomical abnormality. The latest techniques of surgical removal of hiatal hernias aimed at improving the results of surgical treatment are described in this article.
... В настоящее время имеется большое число методов хирургической коррекции диафрагмальных грыж, что на самом деле говорит об отсутствии методики, полностью удовлетворяющей практикующих хирургов по своей эффективности и безопасности [5]. ...
... В то же время, наложение швов на неизмененные ткани с целью надёжной их фиксации обуславливает чрезмерное сужение пищеводного отверстия и развитие стойкой послеоперационной дисфагии. Перечисленные недостатки хирургической коррекции диктуют необходимость совершенствования техники проведения операций [5]. ...
Hiatal hernia amounts to 90% of all diaphragmatic hernias. According to data obtained from large-scale epidemiological studies in Europe and the USA, esophageal hernias may be revealed in 30-40% of the population, 15% among which require surgical treatment. The occurrence rate equals 91% for small hernias, 6% for large hernias and 3% for giant hernias. The article presents a review of literature dated 2011-2020 and devoted to results of operative treatment of hiatal hernia of different sizes. The search for the publications was performed in the following databases: Web of Science, Scopus, PubMed, e-library, Ulrich's Periodicals Directory, Google Scholar and AGRIS. There is a large number of methods for surgical correction of diaphragmatic hernia. However, strict indications to their application have not been developed to the date. Alloplasty provides for improvement of the clinical picture and of the patients’ quality of life, but bears quite a high risk of recurrence. To this day, treatment of hiatal hernia frequently involves application of various prosthetic materials with their certain advantages and disadvantages. Therefore, the search for optimal surgical methods for treatment of diaphragmatic hernias of different sizes continues and requires further investigation.
... Among literature reported these complications, the most severe are mesh erosion and migration, which may occasionally necessitate esophagectomy [48,49]. A review by Furnée E concluded that the incidence of mesh erosion was 0.2%, while the overall rate of meshrelated complications was 0.5% [50], Some studies suggest that the true incidence of mesh erosion or migration may be underestimated. A potential explanation for the reported low incidence is the lack of long-term follow-up in some studies, as mesh erosion may occur several years after hiatal hernia repair [51].The possible causes of mesh erosion include the continuous movement of the esophageal hiatus during respiration, esophageal peristalsis, coughing, and vomiting. ...
Purpose
The placement of synthetic mesh during laparoscopic hiatal hernia repair has been verified to reduce postoperative recurrence, but mesh erosion and other related complications may occur to synthetic mesh, and our aim was to verify the safety and efficacy of biological mesh in hiatal hernia repair.
Methods
Patients with hiatal hernia who were treated at a tertiary teaching university hospital from December 2020 to May 2023 were prospectively included in this study. General clinical data, hernia-related data, and intraoperative data were collected, and the patients were followed up at 1, 3, 6, and 12 months after surgery, after 12 months, follow-up as needed for primary outcome until September 2024. The following parameters were recorded during follow-up visit: gastroesophageal reflux symptoms, Gastroesophageal reflux disease-Health related quality of life (GERD-HRQL) questionnaire, postoperative recurrence, mesh-related complications and patients’ overall satisfaction.
Results
A total of 82 patients with hiatal hernia were included in this study. The mean age of the patients was 62.68 ± 15.93 years, mean BMI 24.81 ± 4.05 kg/m², the average operation time was 128.21 ± 39.20 min. There was statistically significant improvement of GERD symptom postoperative (p<0.05). 72 cases (93.5%) were rated as “Great” on the GERD-HRQL at the 12 months after surgery; 65 cases (84.4%) were rated as “very satisfactory” on the overall satisfaction scale at the 12 months after surgery. 6 patients (7.3%) experienced recurrences, with no mesh-related complications reported during the follow-up.
Conclusion
At a mean follow-up of 25.43 ± 10.38 months, the present study showed that laparoscopic hiatal hernia repair with biologic mesh results in low rates of 1-year recurrence and complications and increased patient satisfaction.
... In 2016, Galvani and others showed that robotic surgery for the treatment of paraesophageal hernia was feasible and safe [29] as compared to results of laparoscopic approach detailed in a systematic review published 3 years earlier [30]. As corroborated in other studies, total operative time, the number of complications, and consequently the length of hospitalization tend to decrease with the experience of the surgeon and his team [20,26]. ...
Robotic surgery has become increasingly prevalent in UGI surgery over the last decade, particularly for treating hiatal hernias. Voluminous hiatal hernias, defined as the herniation of 30–50 % of the stomach into the thorax, often require surgical intervention due to associated dysphagia and potential severe complications. Given the challenges of repairing voluminous hiatal hernias, especially in elderly and fragile patients, the surgical technique should be optimal. Robotic surgery affords excellent visualization, allowing high mediastinal dissection and precise hiatus reconstruction. Despite the clear technical advantages, it remains to be demonstrated if the robotic approach matches the outcomes of conventional laparoscopic techniques. We review here the fundamentals of hiatal hernia surgery and describe our surgical technique using the da Vinci Xi robot to operate voluminous hiatal hernias. Additionally, we performed a systematic research analysis and selected recent publications focusing on robotic surgery for voluminous hiatal hernias. Recent studies report comparable complication rates, recurrence, and hospital stay lengths between robotic and laparoscopy surgery. Initial robotic procedures had longer operative times, which decreased with surgeon experience. Most of the studies were observational and retrospective, reporting the experience of a single center. Robotic surgery appears to be a viable option with similar complications rates to laparoscopic surgery under optimized conditions. Current literature supports the broader adoption of robotic surgery for voluminous hiatal hernias. However, prospective randomized studies are needed to further validate its use.
... The primary concern regarding the use of mesh is the long-term risk of mesh erosion into the esophagus and other adjacent vital structures. To avoid or reduce this risk, the synthetic mesh has been abandoned in favor of biological meshes (6,(13)(14)(15)(16)(17)(18). However, results from more recent reports suggest that the long-term durability of mesh (irrespective of type) and suture cruroplasty did not differ. ...
Background
Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.
Patients and methods
All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II–IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.
Results
The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.
Trial Registration
ClinicalTrials.gov , identification number NCT04179578.
... This result was concordant with the systematic review of Furnée et al. which indicated a better outcome in terms of recurrence with mesh repair. They also pointed out that there are many kinds of meshes available and that there was a lack of randomized controlled studies to assess the most effective ones [5]. ...
Introduction: Giant hiatal hernia represents 0.3–15% of all hiatal hernia. Its complication such as the strangulation of the stomach are life-threatening. Therefore, in most of the cases it must be surgically handled. Case Report: We report the case of a 74-year-old patient with giant hiatal hernia. He presented with sub-acute symptoms (e.g., vomiting, appetite loss, and hematemesis). Considering the symptomatology and complementary tests, we decided to perform a laparoscopic hernia repair using mesh reinforcement. We provided a commented operative video to describe the surgical procedure. We then discussed the surgical technique and decided how to conduct a safe and efficient repair. Conclusion: A surgical approach is the recommended treatment in most giant hiatal hernia due to its life-threatening complications. The technique should be tailored to the patient. Although there is no consensus whether to use a mesh reinforcement, we believed that a cautious mesh placement should be considered when the crura are of poor quality. Surgeons should also be cautious with the fundoplicature and the risk of stricture, therefore we propose the systematic use of a tube to test the passage in the esophago-gastric junction.
... Advantage: the possibility of plastics of giant hernia defects, where it is impossible to safely sew atrophic and located at a great distance from each other legs of the diaphragm. The drawbacks of "inlay" plastics are even greater than with the "onlay" technique, the possibility of direct contact of the front edge of the mesh with the Oesophagus and the development of postoperative complications, especially if a rigid polypropylene or polytetrafluoroethylene implant is used, and a high probability of recurrence due to less durable singlelayer plasticity, as well as the prolacle edge of the free implant[5].Therefore, SAGES' clinical recommendations for the treatment of diaphragm hernias say that this technique cannot be used.The third technique is a modification of the first and consists in "onlay" strengthening of the cruroraphya with a whole mesh of square or rounded shape with a keyhole in the form of a keyhole around the esophagus or separately stitched together semicircular areas in front and behind from the esophagus. The advantage is the possibility of plastic defect not only behind the esophagus, but also ahead of it.The downside of "onlay" by strengthening the cruroraphy with a whole mesh is the high frequency of postoperative complications due to the circular collision of the implant with the Oesophagus, which is amplified by the shrivelling of the mesh, especially when using rigid polypropylene implants. ...
... No consensus was reached on the importance of mesh use and mesh type [23]. Furne'e et al. [45] published the results of a web-based questionnaire on the treatment of PEH completed by 165 European surgeons as defined by the European Association for Endoscopic Surgery. The majority of respondents (77.6 %) used a mesh selectively, depending on the size of the hiatus and the tension of the sutures during crurorrhaphy. ...
The literature review focuses on the controversial issues regarding the treatment of paraesophageal hernia. The limitations of the current classification of hiatal hernias are highlighted. It is irrelevant and does not meet clinical needs. Objective criteria for its improvement are proposed. Data on the prevalence and course of hiatal hernias are given. Their pathogenetic factors and diagnostic methods are underlined. Considerable emphasis is placed on the paraesophageal hernia treatment strategies in patients with an asymptomatic and mildly symptomatic clinical course of the disease. Arguments are presented in favour of both wait‑and‑see tactics and planned hernioplasty. The choice of hernioplasty technique, especially in the case of giant hernias, the feasibility and indications for the use of mesh implants depending on their shape and composition, and the potential complications of allogenioplasty are the main topics for discussion. The problem of selecting a fundoplication method is addressed while weighing the advantages and potential side effects of employing various fundoplication modifications. The effects of correcting a short esophagus and eliminating the axial pressure on the esophageal hiatus are thoroughly evaluated, as these conditions increase the risk of hernia recurrence. The authors concluded that there are many controversial issues in the treatment of paraesophageal hernia. A consensus is needed on the classification of paraesophageal hernias, which would meet the urgent needs of choosing the method of operative delivery, and, in particular, the definition of the concepts of «large hernia» and «giant hernia.» Further research is required on issues such as the indications for operative treatment of paraesophageal hernias, especially in the case of asymptomatic large hernias and incarcerated hernias; the feasibility of using implants for plastic surgery of the esophageal hiatus; the choice of a fundoplication method; the diagnosis and correction of a short esophagus; and methodology for evaluating long‑term treatment outcomes.
... Historically, a significant number of patients with GPHH have been asymptomatic and this has caused many practitioners to recommend conservative treatment, especially in the elderly population. [19][20][21] In this study, most patients were symptomatic. Recently, Carrott et al. 22 showed that 99% of patients had at least four symptoms related to their GPHH. ...
Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5–10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson’s score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.
... The recurrence rate was still high: 54% vs. 59% for primary repair (p = 0.7). There is variable evidence supporting mesh use [4][5][6][7][8], but even so, its use remains high [9][10][11] because of its long-term recurrence rate [12]. ...
Paraesophageal hernias (PEH) have a high recurrence rate, which can justify the use of a mesh during their repair. Mesh use in PEH repair is highly debated as it can lead to many complications like erosion and migration of the mesh, like in our case.
Here, we present a case of a 23-year-old woman operated on multiple occasions for a recurring PEH and who presented an intraesophageal migration of the mesh. Partial upper gastrectomy and lower esophagectomy were performed to remove the mesh and the recurrent hernia was repaired using primary sutures of the hiatus. The surgery was without complications and there are no signs of recurrence up to a year later.
Reoperation on a recurring PEH can be more difficult in case of mesh use in previous intervention and can lead to other complications like mesh erosion or migration, even so, some surgeons choose this option because it has a lower recurrence rate.
... 24 Two separate systematic reviews have, however, suggested that if the hiatus hernia is particularly large, then mesh augmentation may help reduce recurrence rates. 5,25 DH meshes have a different complication profile, with issues such as recurrence and adhesion formation being of higher relevance. Given the young age of congenital DH patients, such complications can still incur serious consequences. ...
Introduction
Mesh implants are regularly used to help repair both hiatus hernias (HH) and diaphragmatic hernias (DH). In vivo studies are used to test not only mesh safety, but increasingly comparative efficacy. Our work examines the field of in vivo mesh testing for HH and DH models to establish current practices and standards.
Method
This systematic review was registered with PROSPERO. Medline and Embase databases were searched for relevant in vivo studies. Forty-four articles were identified and underwent abstract review, where 22 were excluded. Four further studies were excluded after full-text review—leaving 18 to undergo data extraction.
Results
Of 18 studies identified, 9 used an in vivo HH model and 9 a DH model. Five studies undertook mechanical testing on tissue samples—all uniaxial in nature. Testing strip widths ranged from 1–20 mm (median 3 mm). Testing speeds varied from 1.5–60 mm/minute. Upon histology, the most commonly assessed structural and cellular factors were neovascularisation and macrophages respectively ( n = 9 each). Structural analysis was mostly qualitative, where cellular analysis was equally likely to be quantitative. Eleven studies assessed adhesion formation, of which 8 used one of four scoring systems. Eight studies measured mesh shrinkage.
Discussion
In vivo studies assessing mesh for HH and DH repair are uncommon. Within this relatively young field, we encourage surgical and materials testing institutions to discuss its standardisation.
... of the hernia sac [3,4]. Furthermore, various studies have reported that rates of recurrence for complex HH following laparoscopic repair remain high up to 54% [5][6][7][8]. ...
Background
Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of general surgery. We aimed to evaluate the learning curve for RALS procedures involving repair of hiatal hernias.MethodsA series of robotic-assisted hiatal hernia (HH) repairs were performed between 2013 and 2017 by a surgeon at a single institution. Data were entered into a retrospective database. Patient demographics and intraoperative parameters including console time (CT), surgery time (ST), and total operative time (OT) were examined and abstracted for learning curve analysis using the cumulative sum (CUSUM) method. Assessment of perioperative and post-operative outcomes were calculated using descriptive statistics.ResultsThe average age of the patients was 57.4 years, average BMI was 29.9 kg/m2, median American Society of Anesthesiologists (ASA) classification was 2, and average Charlson Comorbidity Index (CCI) score was 2.8. The series had a mean CT of 132.6 min, mean ST of 145.1 min, and mean OT of 197.4 min. The CUSUM learning curve for CT was best approximated as a third-order polynomial consisting of three unique phases: the initial training phase (case 1–40), the improvement phase (case 41–85), and the mastery phase (case 86 onwards). There was no significant difference in perioperative complications between the phases. Short-term clinical outcomes were comparable with national standards and did not correlate significantly with operative experience.Conclusions
The three phases identified with CUSUM analysis represented characteristic stages of the learning curve for robotic hiatal hernia procedures. Our data suggest the training phase is achieved after 40 cases and a high level of mastery is achieved after approximately 85 cases. Thus, the CUSUM method serves as a useful tool for objectively evaluating practical skills for surgeons and can ultimately help establish milestones that assess surgical competency during robotic surgery training.
... Введение В данной работе представлен анализ результатов ретроспективного рандомизированного исследования, проведённого с 2012 года в рамках поиска оптимальной техники хирургической операции диафрагмальных грыж в зависимости от размеров грыжевого дефекта с использованием задней крурорафии и различных имплантатов. В статье приведены результаты использования способа герниопластики больших и гигантских диафрагмальных грыж с применением сетчатой конструкции из медицинского биокарбона [1][2][3][4][5][6][7][8][9][10]. ...
Aim . Highlighting the immediate and long-term results of using a biocarbon implant in comparison with the standard method of using a polypropylene implant when operating on patients with large and giant diaphragmatic hernias.
Materials and methods . All patients were divided into 2 study groups, which underwent alloplasty with various implants: Group I of 221 patients who underwent alloplasty with a polypropylene mesh implant (171 patients with large hernias with an area of 10–20 cm2 and 50 patients with giant hiatal hernias with the area of the hernial defect is more than 20 cm2); Group II of 79 patients who underwent original alloplasty with a two-layer biocarbon mesh implant (50 patients with large hernias and 29 patients with giant hiatal hernias). Postoperative complications were classified according to the Clavien-Dindo scale. The De Meester Index was used as a comparison criterion.
Results . The results of surgical treatment are pilot and representative, which determine the further tactics and direction of improving operations to remove large and giant diaphragmatic hernias. The data on the use of a two-layer biocarbon implant and a comparison with a polypropylene implant during onlay repair of large and giant diaphragmatic hernias are presented.
Conclusion . There were significant differences in relapses of all types in favor of a biocarbon implant (5,6 versus 22,8%; p < 0,0001; Fisher's exact test).
... ORIGINAL ARTICLE Введение В статье представлен анализ результатов ретроспективного рандомизированного исследования, проведенного с 2012 г. в рамках поиска оптимальной техники хирургической операции хиатальных грыж в зависимости от размеров грыжевого дефекта с использованием задней крурорафии и различных имплантатов. Приведены результаты использования способа герниопластики больших и гигантских диафрагмальных грыж с применением сетчатой конструкции из медицинского биокарбона [1][2][3][4][5][6][7][8][9][10]. ...
Aim. The article discusses the results of a study using a patented method of two-layer laparoscopic repair of large and giant hiatal hernias using a biocarbon implant in comparison with other surgical techniques. Materials and methods. 716 patients were divided into 3 study groups based on the area of the size of the esophageal hernia defect: group I (314 patients) – with small (less than 5 cm2) and medium (5–10 cm2) hiatal hernias, that is, up to 10 cm2, which hernioplasty was performed only by the method of posterior cruraphy; group II (323 patients) – with large hernias 10–20 cm2: subgroup 1 (92 patients) underwent posterior cruraphy, subgroup 2 (231 patients) – alloplasty. Depending on the alloplasty technique, subgroup 2, in turn, was divided: subgroup A (89 people) – hernioplasty with a polypropylene implant and subgroup B (142 people) – hernioplasty with a medical biocarbon construction. Study group III (79 patients) – patients with giant diaphragmatic hernias of more than 20 cm2 using alloplasty: subgroup A (29 people) – hernioplasty with a polypropylene implant and subgroup B (50 patients) – alloplasty with a medical biocarbon construction. Results. When comparing group I with subgroup 1 of group II, the following results were obtained. Statistically significant differences were found in the degrees and types of diaphragmatic hernias. The average age of patients and statistical differences for it were insignificant. When comparing subgroup 1 with subgroup 2 of group II, statistically insignificant differences were found in the degrees and types of hiatal hernias. The difference in the average age of patients was also statistically insignificant. The difference in the average age of patients was also statistically insignificant. When comparing subgroup A with subgroup B of group II, statistically insignificant differences were found among themselves in the degrees and types of hiatal hernias. When comparing subgroup 2 of group II with group III, the difference turned out to be statistically significant in the distribution of patients by types and degrees of diaphragmatic hernias. When comparing subgroup A with subgroup B of group III by degrees and types of hiatal hernias, statistically insignificant differences were revealed. Conclusion. Posterior cruraphia in small and medium diaphragmatic hernias had significant statistical differences in types and degrees compared to that in large hernias, as well as in the average area of the hernial defect. Posterior cruraphia with hernioplasty in large hiatal hernias did not differ statistically significantly according to any of the criteria. Plastic surgery with a polypropylene implant with alloplasty of a biocarbon implant for large hernias did not differ significantly according to any of the criteria. Hernioplasty for large hiatal hernias, when compared with giant hernias, differed significantly only in the degree and type, as well as in the area of the hernial defect. Onlay plastic surgery with a polypropylene implant with alloplasty of biocarbon structures for giant hernias did not differ significantly according to any of the criteria, except for gender distribution, which did not have significant fundamental significance, which made it possible to make a more correct comparison of the results of surgical interventions in these research subgroups.
... Second, and more concerning, is the risk of mesh related complications, including erosion, stricture, and dysphagia. The true incidence of such complications is unknown, as many studies provide only short-term data, and limited descriptions of complications (8,9). ...
... For example, in a case of infected ventral hernia, generally, absorbable synthetic meshes are used, however, since they are absorbed, recurrence rate is very high and additional surgical intervention is needed to achieve permanent repair [5,8]. PTFE and PP are the most common meshes used to repair large ventral hernias [9,10]. However, when the macroporous meshes are placed so that they come in contact with abdominal viscera, they are associated with the development of bowel adhesions, obstructions, and enterocutaneous fistulae. ...
Using the mesh for hernia repair is the most common type of hernia surgery. There are many types of meshes made of various synthetic materials, but all of these meshes have their own respective disadvantages. The aim of this study was to provide preliminary results of a non-randomized clinical trial evaluation of novel porcine grafts XI-S+® (Colorado Therapeutics LLC. USA) for ventral and inguinal hernia repair. All patients underwent a standardized surgical procedure. Onlay surgical repair technique has been performed in ten patients with ventral hernia and Lichtenstein tension-free method has been used for ten patients with inguinal hernia repair. The XI-S+® mesh fixation was performed with multiple simple interrupted sutures using prolene thread. The average age of the patients with ventral hernia was 54±14 years, and 30% of patients were female and 70% of patients were male. The average age of the patients with inguinal hernia was 62.5±9.4 years, and 10% of patients were female and 90% of patients were male. The average hospitalization length was 2 days. During three years of observation, no recurrence of hernia was observed in patients. The XI-S + ® mesh has anti-adhesive properties, is extremely resistant to infections, provides favorable conditions for engraftment, early activity and patient rehabilitation. The clinical studies of the patients that underwent ventral and inguinal hernia repair using XI-S+® mesh have shown that the post-operative pain was minimal and easily controlled by the use of analgesics. As for the sensation of the mesh, in some patients it has been present up until 1 month from surgery, but it fully disappeared by the end of the 3rd month.
... В статье приведены результаты использования способа герниопластики больших и гигантских диафрагмальных грыж с применением сетчатой конструкции из медицинского биокарбона [1][2][3][4][5][6][7][8][9][10]. ...
The aim of the research. The work considers the results of posterior cruraraphy along with hernioplasty, using polypropylene and biocarbon implant in surgical treatment of diaphragmatic hernias of various sizes. Material and methods. Totally 716 patients were divided into 3 study groups, based on the size of esophageal hernia defect: group I (314 people) – with small and medium size of hiatal hernias, who underwent posterior cruraphy; group II (323 patients) – with large hernias: subgroup 1 (92 patients) underwent posterior cruraphy, subgroup 2 (231 patients) – underwent hernioplasty. Subgroup 2 was divided into: subgroup A (89 people) – plastic surgery with polypropylene implant and subgroup B (142 people) – plastic surgery with biocarbon implant. Group III (79 patients) – patients with giant hiatal hernias: subgroup A (29 people) – plastic surgery with polypropylene implant and subgroup B (50 patients) – biocarbon construction. Results. While comparing group Ӏ with group II, subgroup 1 signifi cant diff erences were found in the degrees and types of hernias. Th e age of patients was not statistically important. While comparing subgroup 1 with subgroup 2 of group II, statistically insignifi cant diff erences were revealed in degrees and types of hernias. Th e age of patients was also statistically insignifi cant. While comparing subgroup A with subgroup B of group II, insignifi cant diff erences were revealed in degrees and types of hernias. While comparing subgroup 2, group II with group III, the diff erence turned out to be signifi cant in types and degrees of hernias. While comparing subgroup A with subgroup B, group III, statistically insignifi cant diff erences were revealed in the degrees and types of hiatal hernias. Conclusion. Posterior cruraphy in small and medium diaphragmatic hernias differed in types, degrees and size of hernia defect in comparison to the one in large hernias. Posterior cruraphy with plasty for large hernias did not diff er signifi cantly according to any of the criteria. Plastic surgery by polypropylene implant with biocarbon in case of large hernias did not diff er signifi cantly by any criteria. Plastic surgery for large hernias compared to giant ones, diff ered only in the degree and types, as well as in hernia defect size. Plastic surgery by polypropylene implant with biocarbon in giant hernias did not differ in any criteria, except for gender distribution, which was not signifi cant, that made it possible to compare treatment results in these subgroups more correctly.
... Nevertheless, the stringently performed non-absorbable mesh-augmentation that we used to reinforce hiatal repair in all robot-assisted operations, as compared to 53% in the laparoscopic group, partially accounts for the extended duration of Rob-G operations. In our experience, meshes are particularly useful for larger hernia repair, and their application is easier in robotassisted operations [29][30][31][32]. ...
Background
Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).Methods
All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8–53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease–Health-Related Quality of Life (GERD-HRQL) questionnaire.ResultsA total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.Conclusion
While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.
... For management of hiatal hernias two technical aspects that potentially affect the outcome are still debated. These relate first to mesh-augmented hiatoplasty (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11) and, second, to 360 • Nissen fundoplication vs. 270 • Toupet fundoplication (1)(2)(3)(12)(13)(14). So far, the guidelines to not contain any clear recommendations on either of these two surgical techniques. ...
Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions.
Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared.
Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates.
Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.
... 2 The repair of large or paraesophageal hernias (PEHs) is particularly challenging, and recurrences may be due to the low quality of the crura and size of the hiatal defect. 3 In an effort to reduce the recurrence rate, surgeons began performing mesh-reinforced cruroplasty with nonabsorbable synthetic meshes, such as polypropylene or polytetrafluoroethylene. 4 However, the use of non-absorbable mesh has been associated with certain complications, including erosions in the stomach, esophagus, and other surrounding visceral organs. Reports of these complications have prevented the widespread acceptance of prosthesis with nonabsorbable mesh. ...
Background:
Laparoscopic repair of hiatal hernia (HH) is associated with a considerable failure rate. Compared to suture repair alone, mesh-reinforced cruroplasty may be associated with fewer short-term recurrences, yet its use remains controversial. The aim of this study was to analyze the current literature assessing the use of Bio-A absorbable synthetic mesh in the reinforcement of primary crural closure after laparoscopic HH repair.
Methods:
A systematic review of primary literature in the MEDLINE and PubMed databases was conducted. We searched for investigations reporting patient outcomes in laparoscopic HH repair with onlay Gore Bio-A tissue reinforcement (W. L. Gore & Associates, Inc.) published between January 2008 and December 2019. The primary outcome was anatomical recurrence rate. Secondary outcomes were complication rate, symptomatic outcomes, and mortality.
Results:
Eight studies met inclusion criteria. There were two prospective and six retrospective cohort studies. In the included studies, laparoscopic HH repair was performed with Bio-A absorbable synthetic mesh in 734 patients. The anatomical recurrence data were extracted across all studies, and an objective recurrence was identified in 21/280 (7.5%) patients. There was only 1 (0.17%) mesh-related complication in the included studies.
Conclusions:
The use of Bio-A absorbable synthetic mesh in the repair of HHs may be promising, as it offers low rates of anatomical recurrence and mesh-related complications, but more data are still necessary to validate these findings. This collective review of literature is a basis for future randomized controlled trials to identify the most effective and safe mesh in the long term.
... Similarly, a survey among SAGES members [10] showed 25% of surgeons used mesh in more than half of their PEH repairs and the recurrence rates were still high (59% in primary repair compared to 54% in mesh repairs (p = 0.7)). Despite the variable evidence supporting the routine use of mesh [10][11][12][13][14], its use is relatively high [15][16][17] presumably due to the high long-term recurrence rates [18]. There are a number of published observational studies supporting the routine use of mesh, demonstrating lower rates of recurrence with short-term follow-up. ...
Background
Paraoesophageal hernias (PEH) have a high recurrence rate, prompting surgeons to consider the use of mesh reinforcement of the hiatus. The risks and benefits of mesh augmentation in PEH repair are debated. Mesh-related complications including migration and erosion are considered in this publication.DesignA systematic literature review of articles published between 1970 and 2019 in Medline, OVID, Embase, and Springer database was conducted, identifying case reports, case series and observational studies of PEH repair reporting mesh-related complications.ResultsThirty-five case reports/series of 74 patients and 20 observational studies reporting 75 of 4200 patients with mesh complications have been included. The incidence of mesh-related erosions in this study is 0.035%. PTFE, ePTFE, composite and synthetic meshes were frequently associated with mesh erosion requiring intervention. Complete erosions are often managed endoscopically while partial erosions may require surgery and resection of the oesophagus and/or stomach.Conclusions
Mesh-related complication is rare with dysphagia a common presenting feature. Mesh erosion is associated with synthetic mesh more frequently in the reported literature. A mesh registry with long-term longitudinal data would help in understanding the true incidence of mesh-related complications.
... The authors found a statistically significant reduced 6 months recurrence rate for mesh repair (9% vs. 24%, p = 0.04) with no statistically significant differences in the long-term (5-year) [20]. Similarly, recent systematic reviews and meta-analyses showed statistically significant reduced recurrence rate for laparoscopic mesh-reinforced crura repair [21][22][23]. Up to date, no definitive evidence exists to strongly recommend mesh augmentation for large hiatal hernia repair because of the low ''quality of evidence'' related to the data heterogeneity, inconsistency of hernia definition, hernia recurrence, and technical variations [24]. ...
Background
Different surgical variations have been described for laparoscopic crural repair however, the technique is not standardized and left to the surgeons’ preference.Objective
The purpose of this study is to describe a standardized “patient tailored” approach for laparoscopic posterior cruroplasty in the setting of elective hiatal hernia repair.Methods
Retrospective single-center study was conducted (November 2015 to November 2019). The technical aspects of a standardized “patient tailored” laparoscopic posterior crural repair are described. Perioperative outcomes and patients’ quality of life, measured with the disease specific Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and generic Short Form-36 (SF-36), were analyzed.ResultsOne hundred and forty-one patients were treated for symptomatic hiatal hernia according to the described “patient tailored” concept. Overall, 102 (72.3%) patients underwent simple suture repair while simple suture repair buttressed with biosynthetic resorbable U shaped mesh [Phasix ST®-Bard] was used in 39 (27.7%) patients. Toupet fundoplication was fashioned in all patients. The median operative time was 131 min (IQR 55–240). No intraoperative complications or conversion to open surgery occurred. The median postoperative stay was 1.8 days (range 1–7). The overall postoperative complication rate was 4.2%. The median follow-up was 21 months (IQR range 1–34) with 102 patients having a minimum follow-up of 6 months. Recurrent hernia was diagnosed in three patients (2.1%), but none required reoperation. No mesh-related complications occurred. Compared to baseline, the median GERD-HRQL (p = 0.003) and all SF-36 items (p < 0.001) were significantly improved.Conclusion
The application of a standardized “patient tailored” concept for laparoscopic posterior cruroplasty seems safe and effective in the medium-term follow-up with promising perioperative outcomes and quality of life improvement. This approach may be valuable to assure procedure reproducibility, standardization, and to uniformly interpret the outcomes.
Rationale
Surgical repair is considered the optimal treatment for hiatal hernia (HH); however, postoperative complications, such as obstruction, can occur, which may complicate recovery. This case report details a patient who experienced postoperative obstruction following laparoscopic adhesiolysis combined with transabdominal HH repair and Nissen fundoplication for recurrent esophageal HH.
Patient concerns
A 64-year-old female presented with a 3-year history of worsening shortness of breath during physical activity. She also reported upper abdominal pain, postprandial vomiting, and difficulty swallowing, all of which significantly compromised her quality of life. The patient had a 5-year history of diabetes, with no notable family or genetic history. Three years prior, she underwent laparoscopic HH repair at a local hospital, but specific details of that surgery were not available.
Diagnoses
HH was confirmed through computed tomography scans of the chest and upper abdomen, as well as serial examinations of the upper digestive tract.
Intervention
On March 9, 2023, the patient underwent laparoscopic abdominal adhesion release, transabdominal HH repair, and Nissen fundoplication. Postoperatively, she received parenteral nutrition, acid inhibition, and symptomatic treatment for deswelling to alleviate abdominal pain and vomiting. However, the patient was unable to tolerate oral intake due to obstruction.
Outcomes
A contrast study revealed high obstruction at the distal esophagus, specifically at the junction of the stomach and esophagus, likely at the cardia. Subsequently, on April 6, 2023, the patient underwent a second laparoscopic exploration and adhesiolysis under general anesthesia. Postoperatively, the patient recovered well and was discharged on April 14, 2023. During the 12-month follow-up on April 30, 2024, she reported returning to normal daily activities with no complaints of discomfort.
Lessons
This case highlights that laparoscopic adhesiolysis combined with transabdominal HH repair and Nissen fundoplication can effectively address recurrent esophageal HH along with postoperative obstruction. The findings provide important insights for the individualization of surgical procedures for patients with HH.
Purpose:
The use of prosthetic mesh to augment suture repair of large paraoesophageal hernias is widespread but controversial. Our aim was to identify the risk of mesh-specific complications from a large series of consecutive patients undergoing hiatal hernia repair augmented with a lightweight polypropylene mesh (TiMesh) over a 12-year period.
Methods:
A retrospective cohort study of prospectively collected data for patients undergoing prosthesis reinforced hiatal repair with TiMesh between February 2005, and October 2017 were identified. Pre-operative, intra-operative and post-operative data were collected for all patients undergoing hiatal repair.
Results:
In total, 393 patients underwent TiMesh augmented hiatal repair between February 2005 and October 2017. There were no intraoperative mesh-specific complications. Mesh was explanted in one patient (1/393, 0.25%) who underwent emergency paraoesophageal hernia repair complicated by sepsis. Asymptomatic mesh erosion was found in two patients (2/393, 0.51%) at endoscopy three and nine years following surgery, respectively. No cases of oesophageal or hiatal strictures were identified.
Conclusion:
From our large series, albeit without routine endoscopic and radiological follow-up, we demonstrate acceptably low rates of mesh related complications. We identified two cases of asymptomatic erosion during 393 TiMesh repairs, and the rate of mesh-specific complications in this patient series is low. This unit will continue to perform selective TiMesh hiatal repair in cases where a suture repair only is felt to be inadequate at the time of surgery. For the purposes of patient consent and ongoing discussion, we report the risk of mesh erosion and mesh explantation to be 0.51% and 0.25%, respectively.
Surgical meshes composed of bioinert polymers such as polypropylene are widely used in millions of hernia repair procedures to prevent the recurrence of organ protrusion from the damaged abdominal wall....
Redo-surgery is challenging especially when it is associated with obesity. These complexities are heightened for patients undergoing bariatric surgery on a background of previous hiatal surgery. This risk can manifest as increased surgical morbidity and mortality. Meticulous planning and a good understanding of the anatomical alterations is required to safely perform re-do surgery in this area. The relationship of GERD with obesity and knowledge of different approaches and techniques is paramount for successful outcomes.
Redo-surgery is challenging especially when it is associated with obesity. These complexities are heightened for patients undergoing bariatric surgery on a background of previous hiatal surgery. This risk can manifest as increased surgical morbidity and mortality. Meticulous planning and a good understanding of the anatomical alterations is required to safely perform re-do surgery in this area. The relationship of GERD with obesity and knowledge of different approaches and techniques is paramount for successful outcomes.
Objective. Studying of complications, connected with application of the net implants in patients with large hiatal hernias.
Materials and methods. Retrospective investigation was conducted with objective to study complications, connected with application of the net implants in patients with large hiatal hernias, operated in the clinic during period from 2008 to 2018 yr. Of 1168 patients operated on and suffering gastro-esophageal reflux disease as well as hiatal hernias, 817 have had large hernias. In 353 patients with large hernias for strengthening of cruroraphy sutures the net implants were applied. There were used low-weighted implant-net Ultrapro, the composite net Parietex, self-fixating surgical net ProGrip, absorbable net Vicryl, polytetrafluoroethylene net with nitinol carcass, biological net Bio-A. All the patients symptoms were registered, and the quality of life studied.
Results. Complications, caused by the net implants impact, were revealed in 17 (1.5%) patients. In all 17 patients the esophageal structuring have occurred due to pronounced cicatrization in region of the net implant installation. In 6 patients dysphagia due to the net ingrowth into esophageal tissue was observed, and in 2 – chronic inflammatory process in place of the net installation. One patient have had small esophageal perforation with restricted mediastinitis. In 3 patients, in whom the polytetrafluoroethylene nets were installed, their migration into esophageal lumen was revealed. Reoperations were done in all 17 patients. In 7 patients the net was removed completely. In 1 patient the net was removed and mediastinum drained. In 3 patients, in whom polytetrafluoroethylene nets have migrated into esophageal lumen, they were removed endoscopically with further installation of special stents. Results of reoperations were estimated as good in 15 patients. In 2 patients after reoperations dysphagia was observed, which needed a second time balloon dilatation and installation of stent in 1 of them.
Conclusion. Nonabsorbable nets ought to be applied with high technical accuracy, it is necessary to prevent their contact with the esophagus. Application of the polytetrafluoroethylene nets with nitinol carcass for plasty of large hiatal hernias must be forbidden.
Background: While laparoscopic fundoplication is a standard surgical procedure for patients with esophageal hiatal hernias, the postoperative recurrence of esophageal hiatal hernias is a problem for patients with giant hernias, elderly patients, or obese patients. Although there are some reports indicating that reinforcement with mesh is effective, there are differing opinions regarding the use thereof.
Purpose: We investigated whether mesh reinforcement is effective for laparoscopic fundoplication in patients with esophageal hiatus hernias.
Patients and Methods: The subjects included 280 patients who underwent laparoscopic fundoplication as the initial surgery for giant esophageal hiatal hernias, elderly patients aged 75 years or older, and obese patients with a BMI of 28 or higher, who were considered at risk of recurrent hiatal hernias based on the previous reports. Of the subject patients, 91 cases without mesh and 86 cases following the stabilization of mesh use were extracted in order to compare the postoperative course including the pathology, symptom scores, surgical outcome, and recurrence of esophageal hiatus hernias.
Results: The preoperative conditions indicated that the degree of esophageal hiatal hernias was high in the mesh group (p=0.0001), while the preoperative symptoms indicated that the score of heartburn was high in the non-mesh group (p=0.0287). Although the surgical results indicated that the mesh group underwent a longer operation time (p<0.0001) and a higher frequency of intraoperative complications (p=0.037), the rate of recurrence of esophageal hiatal hernia was significantly low (p=0.049), with the rate of postoperative reflux esophagitis also tending to be low (p=0.083).
Conclusions: Mesh reinforcement in laparoscopic fundoplication for esophageal hiatal hernias contributes to preventing the recurrence of esophageal hiatal hernias when it comes to patient options based on these criteria.
Background
Interest in laparoscopic mesh-reinforced hiatal hernia (HH) repair is driven by concern of recurrences following primary suture repair alone. There is need for further evidence on non-absorbable mesh-related complications or the long-term outcomes and patient satisfaction of laparoscopic mesh-reinforced HH repair.
Methods
A retrospective analysis of consecutive patients (2005-2016) of a single surgeon. Patients were further surveyed via telephone and mailed questionnaires to assess long-term satisfaction and outcomes using Visick and gastro-oesophageal reflux disease symptoms assessment scale (GSAS) scores.
Results
174 patients underwent laparoscopic HH repair, either as part of laparoscopic anti-reflux surgery (ARS) or for treatment of para-oesophageal HH in this period and fulfilled the study criteria. Patients with crural defects > 2cm received primary closure and those with larger defects received mesh reinforcement. Primary repair was performed in 28.2% (n=49) and mesh-reinforcement in 71.8% (n=125). HH recurrence (20.4% vs 17.6%, p=0.67) and reoperation rates (16.3% vs 10.4%, p=0.28) were not significantly different between the two groups. GSAS scores (2.1 vs 1.8. p=0.74) and patient satisfaction (p=0.82) were similar. Resolution of symptoms (Visick 1) favoured the mesh-reinforced group (19.4% vs 46.5%, p=0.04). There were no mesh infections or erosions.
Conclusion
In our cohort, laparoscopic non-absorbable mesh-reinforced HH repair of large defects had similar long-term results to primary repair of small defects. There were potential long-term improvements in patient symptomatic outcomes as determined by the Visick score.
This work analyzes Russian and international literature sources that discuss the surgical intervention results for large and giant hiatal hernias. To date, there is no uniform classification of hiatal hernias by the size of the hernial defect. The classifications and algorithms for choosing the plastic method proposed by various authors provide no convincing evidence base. Although there are many methods for surgically correcting hiatal hernia, clear indications for their implementation have not been developed. The postoperative complications and relapses of the disease after surgery represent an unresolved issue. The laparoscopic approach for large and giant hiatal hernias is preferable to open surgery. However, it can lead to serious intra- and postoperative complications, especially in emergency cases. Alloplasty provides clinical improvement and an increase in the quality of life of patients, but has a relatively high risk of recurrence. To date, the treatment of hiatal hernias involves using various prosthetic materials, and their advantages and disadvantages are described in this article. Thus, the search for optimal surgical techniques to treat large and giant hiatal hernias continues.
Aim . The article discusses the results of a study using a patented method of two-layer laparoscopic repair of large and giant hiatal hernias using a biocarbon implant in comparison with other surgical techniques.
Materials and methods . 716 patients were divided into 3 study groups based on the area of the size of the esophageal hernia defect: group I (314 patients) – with small (less than 5 cm ² ) and medium (5–10 cm ² ) hiatal hernias, that is, up to 10 cm ² , which hernioplasty was performed only by the method of posterior cruraphy; group II (323 patients) – with large hernias 10–20 cm ² : subgroup 1 (92 patients) underwent posterior cruraphy, subgroup 2 (231 patients) – alloplasty. Depending on the alloplasty technique, subgroup 2, in turn, was divided: subgroup A (89 people) – hernioplasty with a polypropylene implant and subgroup B (142 people) – hernioplasty with a medical biocarbon construction. Study group III (79 patients) – patients with giant diaphragmatic hernias of more than 20 cm ² using alloplasty: subgroup A (29 people) – hernioplasty with a polypropylene implant and subgroup B (50 patients) – alloplasty with a medical biocarbon construction.
Results . When comparing group I with subgroup 1 of group II, the following results were obtained. Statistically significant differences were found in the degrees and types of diaphragmatic hernias. The average age of patients and statistical differences for it were insignificant. When comparing subgroup 1 with subgroup 2 of group II, statistically insignificant differences were found in the degrees and types of hiatal hernias. The difference in the average age of patients was also statistically insignificant. The difference in the average age of patients was also statistically insignificant. When comparing subgroup A with subgroup B of group II, statistically insignificant differences were found among themselves in the degrees and types of hiatal hernias. When comparing subgroup 2 of group II with group III, the difference turned out to be statistically significant in the distribution of patients by types and degrees of diaphragmatic hernias. When comparing subgroup A with subgroup B of group III by degrees and types of hiatal hernias, statistically insignificant differences were revealed.
Conclusion . Posterior cruraphia in small and medium diaphragmatic hernias had significant statistical differences in types and degrees compared to that in large hernias, as well as in the average area of the hernial defect. Posterior cruraphia with hernioplasty in large hiatal hernias did not differ statistically significantly according to any of the criteria. Plastic surgery with a polypropylene implant with alloplasty of a biocarbon implant for large hernias did not differ significantly according to any of the criteria. Hernioplasty for large hiatal hernias, when compared with giant hernias, differed significantly only in the degree and type, as well as in the area of the hernial defect. «Onlay» plastic surgery with a polypropylene implant with alloplasty of biocarbon structures for giant hernias did not differ significantly according to any of the criteria, except for gender distribution, which did not have significant fundamental significance, which made it possible to make a more correct comparison of the results of surgical interventions in these research subgroups.
Background:
According to recent studies, large hiatal hernias (HH) can be associated with a lower content of type-I and type-III collagen in the phrenoesophageal ligament (POL). We therefore hypothesize that the use of a mesh implant with autologous platelet-rich plasma (PRP) for repair of large HH would have a positive effect on long-term outcome.The purpose of our study was to determine the level of type-I and type-III collagens in the POL of patients with large HH with the aim of improving the technique of HH repair.
Materials and methods:
During the first phase of the study, the collagen content within the POL was assessed in 18 patients with HH and 14 cadaveric specimens without HH. During the second phase, 54 patients with large HH (defined as 10 to 20 cm2), that required surgery were recruited. Laparoscopic repair involved use of a nonabsorbable self-fixating ProGrip mesh infiltrated with 2 to 4 mL of autologous PRP was used for reinforcement of crural repair. Results were assessed using endoscopy, barium swallow, 24-hour impedance-pH monitoring and a quality of life gastroesophageal reflux disease-health related quality of life questionnaire.
Results:
The content of collagen within POL in patients with HH was significantly lower than in the cadaveric specimens without HH. Of the 54 patients undergoing HH repair, all procedures were performed laparoscopically and there were no mortalities in this group. At 48 months, only 2 HH recurrences (3.7%) were detected. During this period, the mean gastroesophageal reflux disease-health related quality of life score decreased from 15.7±5.5 to 5.9±0.6 (P<0.05).
Conclusion:
Our study has shown that the collagen content is reduced in patients with large HH; thus, it is advisable to use mesh for HH repair in such patients. Use of mesh infiltrated in PRP is safe and can have positive impact on results of HH repair.
This article is a continuation of a series of studies on the optimization of techniques and methods of surgical operations for hernias of the esophageal aperture of the diaphragm and is based on the use of the author’s development of a model of a two-layer biocarbon mesh implant. The purpose of this study is to highlight the immediate and long-term results of using a double-layer biocarbon mesh implant in comparison with the standard method of using a polypropylene implant when operating patients with large and giant hiatal hernia. All patients were split into 2 research groups that underwent alloplasty with various implants: Group I of 221 patients who underwent alloplasty with a polypropylene mesh implant (171 patients with large hernias of 10-20 cm2) and 50 patients with giant hernias of the esophageal orifice with the area of the hernial defect exceeding 20 cm2); Group II of 79 patients who underwent an original alloplasty with a bi-layer biocarbon mesh implant (50 patients with large hernias and 29 patients with giant hernia of the esophageal orifice). Postoperative complications were classified according to the Clavien-Dindo scale. De Meester index was used as a comparison criterion. The article discusses the results of operations of 300 patients for large and giant hernias of the esophageal aperture of the diaphragm, of which 79 were operated on using a prototype biocarbon double-layer mesh implant according to the author's patent. The paper presents immediate and long-term results. The results of surgical treatment are pilot and representative, which determine the further tactics and direction of improving operations to remove large and giant hernias of the esophageal opening of the diaphragm. For the first time, data on the use of the author's development of a bi-layer biocarbon mesh implant are presented and compared with a polypropylene mesh implant during an "on-line" plastic repair of large and giant hiatal hernia. Significant differences were obtained in relapses of all types in favor of a biocarbon mesh implant (5,6 versus 22,8%; p < 0,0001; Fisher's exact test).
Giant hiatal hernias represent a small subset of diaphragmatic hernial disease. Characterized by supramesocolic or multidistrict intrathoracic evisceration, they are at greater risk of complications due to the tendency to strangulation and to meso- or organoaxial volvuli as a result of the end-stage of dysautonomic and dysmotilic processes involving the esophagogastric junction. Giant hiatal hernias fall into the category of well-being pathologies and are often concomitant with obesity. Since congenital aetiology is rare, the underlying pathophysiological mechanisms are increased intra-abdominal pressure, morbid obesity, Caucasian race. Nevertheless, this is usually an incidental finding in the absence of suggestive clinical findings and if symptoms arise, they are usually nonspecific (epigastralgia, bloating, reflux). On the other hand, the occurrence of hematemesis, epigastric or atypical chest pain represent worrisome symptoms that may underlie the onset of local complications such as incarceration and volvuli. Surgical management usually appears challenging, usually involving inveterate compartment defects as far as tissue loss of strength making repair complex and usually demanding mesh cruroplasties. A minimally invasive approach has a double utility: an accurate direct dissection control and the undeniable advantages of postoperative functional recovery. However, superiority of minimally invasive surgical approach still claims debate, especially concerning long-term outcomes. A clinical case of a patient with a giant hiatal hernia with organo-axial gastric volvulus and laparoscopic surgically repaired is reported.
BACKGROUND
The use of mesh associated with cruroplasty is still controversial, especially in cases of giant hernias, due to possible complications of the prosthesis reported in the literature, such as infection, chest migration, shrinkage, esophageal and aortic erosion, stenosis and obstruction. This systematic review and meta-analysis aimed to compare the use or not of mesh as a reinforcement in the laparoscopic repair of giant hernias and to determine which technique has the best results in recurrence and complication rates.
MATERIAL AND METHODS
A search was conducted using databases and included prospective and randomized studies. The studies should include patients with giant hernias who have undergone laparoscopic treatment comparatively analyzed between cruroplasty and suture associated with prosthetic reinforcement.
RESULTS
Of the 768 articles analyzed, 8 were selected for systematic review, and 7 were included in the meta-analysis (3 randomized trials with higher evidence strength, 2 randomized trials with lower methodological quality, and 2 prospective cohorts). The meta-analysis showed no statistically significant differences in favor of any of the intervention methods (mesh versus suture cruroplasty) for the different outcomes evaluated: recurrence (RD -0.06, CI [-0.13,0.01], I² 22%, p 0.27); postoperative complications (RD 0.04, CI [-0.01,0.9], I² 5%, p 0.30); deaths (RD -0.01, CI [-0.04, 0.02], I² 0%, p 74); intraoperative complications (RD -0.03, CI [-0.07, 0.1]); reoperation (RD -0.04, CI [-0.10, 0.02], p 0.14).
CONCLUSION
There is no evidence supporting that routine mesh reinforcement in laparoscopic repair of giant hernias decreases recurrence and other complications. Systematic review registration number at PROSPERO: CRD42019147468.
Hiatal hernia repair (HHR) and fundoplication are similarly performed among all hiatal hernia types with similar techniques. This study evaluates the effect of HHR using a standardized technique for cruroplasty with a reinforcing polyglycolic acid and trimethylene carbonate mesh (PGA/TMC) on patient symptoms and outcomes. A retrospective review of patient perioperative characteristics and postoperative outcomes was conducted for cases of laparoscopic hiatal hernia repair (LHHR) using a PGA/TMC mesh performed over 21 months. Gastroesophageal reflux disease symptom questionnaire responses were compared between preoperative and three postoperative time points. Ninety-six patients underwent LHHR with a PGA/TMC mesh. Postoperatively, the number of overall symptoms reported by patients decreased across all postoperative periods (P < 0.001). Patients reported a significant reduction in antacid use long term (P < 0.001). Laryngeal and regurgitation symptoms decreased at all time points (P < 0.05). There was no difference in dysphagia preoperatively and postoperatively at any time point. Individuals undergoing HHR with PGA/TMC mesh experienced improved regurgitation and laryngeal symptoms, and decreased use of antacid medication.
Вивчено віддалені результати хірургічного лікування хворих на гастроезофагеальну рефлюксну хворобу, асоційовану з грижею стравохідного отвору діафрагми. За стандартною методикою (лапароскопічна фундоплікація за Ніссеном) протягом 2004-2019 років, у клініці прооперовано 188 пацієнтів, що склали 1-у групу досліджень. За власною методикою лапароскопічної операції при ГСОД (патент України № 59772) прооперовано 57 хворих, що склали 2-у групу досліджень. Результати лікування вивчали у кожного пацієнта перед операцією і через 3 та 36 місяців після неї. В першій групі, серед інтраопераційних ускладнень було ушкодження селезінки з кровотечею у 5 (2,7 %) хворих і карбокситоракс у 4 (2,1 %) пацієнтів. У післяопераційному періоді на 2-у добу, в одного хворого, розвинулася ТЕЛА. Летальних випадків не було. Рецидив ГСОД і ГЕРХ діагностовано в 4 обстежених пацієнтів (3,9 %) через 36 місяців після операції. В другій групі, рецидив ГСОД і ГЕРХ ‒ в 1 пацієнта (2,6 %). Не було жодного випадку міграції антирефлюсної манжети, післяопераційних гнійно-септичних чи тромбоемболічних ускладнень.
Introduction:
Paraesophageal hernias represent 5%-10% of all primary hiatal hernias and are becoming increasingly more common with the aging of the population. Surgical treatment includes closure of the wide hiatal gap. Achieving tension-free closure is difficult, and several studies have reported lower recurrence rates with the use of mesh reinforcement. The use of this technique, however, is controversial.
Objective and Materials and Methods:
Narrative revision of the literature revising: (1) evidence-based surgery and clinical studies, (2) what the experts say (Delphi), (3) complications of mesh, and (4) long-term results of laparoscopic treatment impact on the quality of life.
Results:
Consensus about the type of mesh continues to be elusive, and we clearly need a higher level of evidence to address the controversy.
Conclusion:
Mesh reinforcement can effectively reduce the hernia recurrence rate. Mesh-associated complications are few, but because they are serious, most experts recommend mesh use only in specific circumstances, particularly those in relation to the size of the hiatal defect and the quality of the crura.
The review of the literature presents the content analysis of surgical treatment of large and giant hernia of the esophageal aperture of the diaphragm as well as the analyses of complications when using the main methods of hernioplasty. Alloplasty of the esophageal aperture of the diaphragm remains a large and unresolved surgical problem, as evidenced by the analyzed literature sources, mainly reviews and clinical recommendations.
Firstly, alloplasty can cause postoperative complications with a frequency of up to 20%, especially when using rigid polypropylene and composite polytetrafluoroethylene mesh implants with circular paraesophageal fixation. Modern biological nets now show high incidence of anatomical relapses, so most specialists continue to use synthetic implants, of which the most promising ones are lightweight, mesh, partially absorbable structures.
Secondly, clear indications for alloplasty have not been developed, for example, according to the size of the hernia of the esophageal opening in the diaphragm, which is the main risk factor for relapses.
Thirdly, it is still not clear what indicator should be used to estimate the size of hernia of the esophageal aperture of the diaphragm and, therefore, it is not clearly defined which hernias are considered small, which are large and which are giant, despite the fact that the three terms constantly appear in the medical literature.
Fourthly, the optimal technique for alloplasty has not been determined with large and especially giant hernias, which would prevent anatomical relapses, and at the same time would not cause postoperative complications.
It is necessary to outline the following ways to solve these problems: to develop effective and at the same time safe methods of alloplasty of large and giant hernias; to determine clear indications for alloplasty of the esophageal opening of the diaphragm, depending on the size of hernias; to create an appropriate, applied classification of hernias of the esophageal aperture of the diaphragm.
Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh.
A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications.
Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (± 13.9); BMI 30.3 (± 5.3); operative time 182 minutes (± 56); and length of stay 2.6 days (± 1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia.
LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No meshrelated complications were seen in this series.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
There is controversy about the tailored or routine addition of an antireflux fundoplication in large hiatal hernia (type II-IV) repair. We investigated the strategy of selective addition of a fundoplication in patients with a large hiatal hernia and concomitant gastroesophageal reflux disease.
Between 2002 and 2008, 60 patients with a large hiatal hernia were evaluated preoperatively and 12 months after surgery by reflux-related symptoms, upper endoscopy, and esophageal 24-h pH monitoring. In patients with preoperatively documented gastroesophageal reflux disease, an antireflux fundoplication was added during hiatal hernia repair.
An antireflux procedure was added in 35 patients and 25 patients underwent hiatal hernia repair only. Preoperative symptoms were improved or resolved in 31 patients (88.6%) in the group who had fundoplication and in 20 patients (87.0%) in the group who did not have fundoplication. In patients with fundoplication, esophagitis was present in 6 patients (22.2%) after surgery and abnormal esophageal acid exposure persisted in 11 (39.3%). Seven patients (38.9%) with hernia repair only developed abnormal esophageal acid exposure, and esophagitis was postoperatively generated in five (27.8%). In neither group did patients have new onset of daily heartburn or dysphagia.
In patients with a large hiatal hernia associated with gastroesophageal reflux disease, addition of a fundoplication during hernia repair yields acceptable reduction of symptoms and does not generate symptomatic side effects. Objective control of reflux, however, is only moderate. Omission of an antireflux procedure in the absence of gastroesophageal reflux disease induced esophagitis in 28% and abnormal esophageal acid exposure in 39% of patients. Therefore, routine addition of an antireflux fundoplication should be recommended.
David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
Several studies have shown that large hiatal hernias are associated with a high recurrence rate. Despite the problem of recurrence, the technique of hiatal herniorrhaphy has not changed appreciably since its inception. In this 3-year study we have evaluated laparoscopic hiatal hernia repair in individuals with a hernia defect greater than 8 cm in diameter.
A series of 35 patients with sliding or paraesophageal hiatal hernias was prospectively randomized to hiatal hernia repair with (n = 17) or without (n = 18) polytetrafluoroethylene (PTFE). All patients had an endoscopic and radiographic diagnosis of large hiatal hernia. Both repairs were performed by using interrupted stitches to approximate the crurae. In the group randomized to repair with prosthesis, PTFE mesh with a 3-cm "keyhole" was positioned around the gastroesophageal junction with the esophagus through the keyhole. The PTFE was stapled to the diaphragm and crura with a hernia stapler.
Patients were followed with EGD and esophagogram at 3 months postoperatively, and with esophagogram every 6 months thereafter. Individuals with PTFE had a longer operation time, but the 2-day hospital stay was the same in both groups. The cost of the repair was 135 more in the group with the prosthesis. There were two complications (1 pneumonia, 1 urinary retention) in the group repaired with PTFE and one complication (pneumothorax) in the group without prosthesis. The group without PTFE was notable for three (16.7%) recurrences within the first 6 months of surgery.
On the basis of these preliminary results it appears that repair with PTFE may confer an advantage, with lower rates of recurrence in patients with large hiatal hernia defects.
Primary repair of a large hiatal hernia is associated with a published recurrence rate of up to 10%; anecdotal rates even higher than this have been reported to the authors. The use of prosthetic material in the repair of other abdominal wall defects has often produced better results than primary repair. We wanted to compare laparoscopic primary repair of large hiatus hernias with laparoscopic primary repair reinforced with prosthetic.
Thirty-one patients with symptomatic gastroesophageal reflux and a hiatal defect 8 cm or greater were randomized to Nissen fundoplication with posterior cruroplasty (n = 16) or Nissen cruroplasty, and onlay of polytetrafluoroethylene (PTFE) mesh (n = 15). All patients underwent preoperative esophagogastroduodenoscopy (EGD) and barium esophagography. After posterior cruroplasty with interrupted nonabsorbable suture, the mesh reinforcement group had an onlay of PTFE placed around the hiatus. A radial slit with 3 cm 'keyhole' (to accommodate the esophagus) was cut into the PTFE. The prosthetic was stapled to the diaphragm, and the two leaves of the slit were stapled to each other. All patients underwent EGD at 3 months and all had esophagrams every 6 months postoperatively. Follow-up ranged from 12 to 36 months.
Length of hospital stay was equal in both groups (2 days). The average cost to the patient with PTFE was USD 1,050 higher than to the patient with primary repair. There were 2 complications (1 pneumonia, 1 urinary retention) in the PTFE group, and 1 complication (pneumothorax) in the primary repair group. There were 3 recurrences (18.8%) in the primary group (p = 0.08, chi(2) test).
The use of PFTE reinforcement for primary repair of large hiatal hernias may result in a lower rate of recurrent herniation compared to primary repair alone.
Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias.
Prospective, randomized controlled trial.
University-affiliated private hospital.
Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter.
Nissen fundoplication with posterior cruroplasty (n = 36) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene (PTFE) mesh (n = 36).
Recurrences, complications, hospital stay, operative time, and cost.
Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was 70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006).
The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.
Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus.
A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected.
The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure.
Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.
The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate.
In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction.
There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique.
To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.
Type III paraesophageal hernias are diaphragmatic defects with the risk of serious complications. High recurrence rates associated with primary suture repair are significantly improved with the use of a tension-free repair with prosthetic mesh. However, mesh in the hiatus is associated with multiple complications. A bio-engineered material from donated human tissue offers an attractive alternative material for hernia repair. This report is on the first series of laparoscopic type III paraesophageal hernia repairs with acellular dermal allografts (Allo-Derm, Lifecell Corporation, Branchburg, NJ) in 11 patients with follow-up evaluation.
From August 2003 to June 2004, 11 patients underwent laparoscopic repair of type III paraesophageal hernias with acellular dermal allografts. Patients were evaluated postoperatively with a symptoms questionnaire and barium esophagram.
All patients were available for follow-up; however, 2 refused a barium esophagram. Average length of hospital stay was 3 days. Follow-up evaluation was at a mean interval of 1 year. Postoperatively, 9 of 11 patients reported no symptoms. Barium esophagram revealed one recurrence in an asymptomatic patient.
Type III paraesophageal hernia can be laparoscopically repaired successfully with acellular dermal allografts.
Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate.
Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis.
Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment.
Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.
Hypothesis
Laparoscopic repair of large hiatal hernia is an appropriate management strategy.Design
A prospective patient series.Setting
A university teaching hospital.Patients
All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998.Interventions
Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus.Main Outcome Measures
Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome.Results
Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%).Conclusions
Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.
We wished to evaluate the long-term effectiveness of the laparoscopic Hill repair in the treatment of type III hiatal hernia. Fifty-two patients underwent laparoscopic repair of a type III hiatal hernia. No esophageal lengthening procedures were performed. Short esophagus was determined from the operative record. Late symptomatic follow-up and a satisfaction questionnaire were completed in 71% (37/52) of patients at a mean of 39 months (range 6 to 84 months). Esophagrams were completed in 65% (34/52) of patients at a mean of 37 months (range to 84 months) after repair. Eighty-one percent were without any adverse symptoms, and 86% rated outcome as excellent or good at 39 months. Symptoms requiring treatment were present in 19% (7/37). Esophagrams revealed a recurrent hernia in 32% (11/34) of patients of whom 36% (4/11) were asymptomatic. Six patients with short esophagus underwent esophagram with one recurrence identified (17%). This was compared with 28 patients without short esophagus, of whom 10 had a recurrence (35%) (P = 0.70). The laparoscopic Hill repair provides long-term satisfaction and relief of symptoms. The incidence of anatomic recurrence on video esophagram is high and does not always correlate with symptoms. The presence of short esophagus does not play a role in recurrence when the Hill repair is used. ( J Gastrointest Surg 2002;6:181–188.)
Giant paraesophageal hernias (PEHs) are associated with progression of symptoms in up to 45 per cent of patients. Recently, many series have reported that laparoscopic repair of PEH is technically feasible, effective, and safe. A retrospective review of the University of Athens tertiary care hospitals patient database and the patient medical records identified 45 patients who underwent elective repair of a giant PEH between 2002 and 2009. Elective laparoscopic repair of a giant PEH was attempted in 45 patients who were treated with Gore-Tex dual mesh with or without Nissen fundoplication. They all had a mesh repair. Intraoperative complications included one pulmonary embolism and one recurrent hernia. The use of a mesh seems to be effective in the treatment of large hernias. It appears to offer the benefit of a shorter hospital stay and a quicker recovery.
Large hiatal hernia (LHH) is defined by a hiatal defect larger than 6cm; repair is indicated whenever it becomes symptomatic. As the risk of recurrence after most techniques is relatively high, laparoscopic repair with prosthetic reinforcement of the hiatus has been proposed to reduce the recurrence rate. Our technique and outcomes are reported.
Laparoscopic prosthetic hiatal reinforcement was performed in 58 patients between August 1997 and October 2009. Prolene(®), Mersilene(®), Goretex(®), and Parietex(®) were the four types of prosthetic material used. Since January 2004, the double-sided V shaped Crurasoft(®) mesh was introduced. Surgical evaluation was based on anatomical and functional criteria: the anatomical results included the presence of recurrent hiatal hernia or esophageal stricture as evaluated by an upper gastrointestinal (UGI) series; functional evaluation was based on a questionnaire concerning long-term patient satisfaction according to the Visick score. Median follow-up was 51 months.
Postoperative UGI series were performed during the initial hospitalization in 37 patients: results were judged to be satisfactory. A routine follow-up UGI series was obtained at 8 months and one year in 46 patients. Two patients underwent reoperation for lower esophageal stricture at 6 months and 16 months. Forty-five patients (77.6%) were reevaluated. Of these, 29 patients (64.4%) were free of symptoms with a good quality of life, eight patients (17.7%) complained of moderate dysphagia and two patients (4.4%) had severe dysphagia. Four patients (8.9%) had moderate pyrosis while severe pyrosis requiring long term PPI treatment was observed in three patients (6.7%). No prosthesis-induced ulceration or perforation was noted. Late follow-up UGI series, performed in 21 patients, showed two patients with severe stricture and a single case of recurrence, but neither of these patients required surgical management.
The addition of mesh reinforcement to surgical repair of large hiatal defects is safe and beneficial in terms of quality of life.
Somatostatin analogues are used for the treatment of pancreatic fistula, with the aim of achieving fistula closure or reduction of output.
MEDLINE, Embase and Cochrane databases were searched systematically for relevant articles followed by hand-searching of reference lists. Data on patient recruitment, intervention and outcome were extracted and meta-analysis performed where reasonable.
Seven randomized clinical trials met the inclusion criteria and included a total of 297 patients with fistulas of the gastrointestinal tract; of these, 102 patients had fistulas of pancreatic origin. Pooling of closure rates showed no significant difference between patients treated with somatostatin analogues compared with controls: odds ratio 1·52 (95 per cent confidence interval 0·88 to 2·61). Owing to inconsistent descriptions, pooling of results was not possible for other endpoints, such as time to fistula closure.
There is no solid evidence that somatostatin analogues result in a higher closure rate of pancreatic fistula compared with other treatments.
We recently reported in a multi-institutional, randomized 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.
During 2002 to 2005, 108 patients underwent LPHER with or without biologic mesh. A standardized symptom severity questionnaire, SF-36 health survey, and upper gastrointestinal series were performed at baseline, 6 months, and during 2008-2009.
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.
Despite frequent radiologic recurrences after LPEHR, symptoms remain well controlled, patient satisfaction is high, and the need for reoperation is low.
Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use.
All patients who had biologic mesh placed at the hiatus and who had been followed for at least 1 year were included. Perioperative data were reviewed, and a questionnaire was administered, designed to identify symptoms of gastroesophageal reflux, other symptoms such as dysphagia, and all other operative or endoscopic interventions that occurred after mesh implantation. In addition, postoperative radiologic and endoscopic studies were reviewed to assess signs of complications related to use of mesh.
There were 126 patients eligible for the study. We were able to contact 73 of these patients, at median follow-up of 45 months. No mesh-related complications were found. The frequency and severity of heartburn, regurgitation, and dysphagia improved significantly compared with preoperative values, and 89% of the patients reported good to excellent results in terms of overall satisfaction. Six patients recorded worsening of dysphagia postoperatively, but after careful work-up and review of each individual case, no case seemed to be directly related to the mesh. No erosions, strictures, or other complications directly related to use of mesh were found. One patient required reoperation due to hiatal hernia recurrence with gastroesophageal reflux disease (GERD) symptoms.
Use of biologic mesh for laparoscopic repair of large, complicated hiatal hernias appears safe. There were no major complications related to the mesh, and overall satisfaction with the operation was very good.
Laparoscopic techniques have led to hiatal procedures being performed with less morbidity but higher failure rates. Biologic mesh (biomesh) has been proposed as an alternative to plastic mesh to achieve durable repairs while minimizing stricturing and erosion. This paper documents the lack of significant dysphagia after the placement of biomesh during hiatal hernia repair.
A retrospective chart review of patients who underwent paraesophageal hiatal hernia repairs with and without biomesh was performed. Hernias were diagnosed with esophagogastroscopy and esophageal manometry. Demographic, procedural, and pre- and post-surgery symptom data were recorded.
Fifty-six patients underwent biomesh repair while 33 patients underwent non-mesh repairs. The procedure time for mesh repairs was significantly longer (p = 0.004). Hospital stays, resting lower esophageal sphincter pressure, and mean contraction amplitudes were similar between groups. Residual pressure was measured to be significantly higher in patients who had mesh repairs (p = 0.0001). Normal esophageal peristalsis was maintained in both groups. At first follow-up, mesh patients complained of more dysphagia and bloating, but non-mesh patients had more heartburn. At second follow-up, non-mesh patients had more symptom complaints than mesh patients.
The addition of biomesh for hiatal hernia repair does not result in significantly increased patient dysphagia rates postoperatively compared with patients who underwent primary repair.
In 2006, we reported results of a randomized trial of laparoscopic paraesophageal hernia repair (LPEHR), comparing primary diaphragm repair (PR) with primary repair buttressed with a biologic prosthesis (small intestinal submucosa [SIS]). The primary endpoint, radiologic hiatal hernia (HH) recurrence, was higher with PR (24%) than with SIS buttressed repair (9%) after 6 months. The second phase of this trial was designed to determine the long-term durability of biologic mesh-buttressed repair.
We systematically searched for the 108 patients in phase I of this study to assess current clinical symptoms, quality of life (QOL) and determine ongoing durability of the repair by obtaining a follow-up upper gastrointestinal series (UGI) read by 2 radiologists blinded to treatment received. HH recurrence was defined as the greatest measured vertical height of stomach being at least 2 cm above the diaphragm.
At median follow-up of 58 months (range 42 to 78 mo), 10 patients had died, 26 patients were not found, 72 completed clinical follow-up (PR, n = 39; SIS, n = 33), and 60 repeated a UGI (PR, n = 34; SIS, n = 26). There were 20 patients (59%) with recurrent HH in the PR group and 14 patients (54%) with recurrent HH in the SIS group (p = 0.7). There was no statistically significant difference in relevant symptoms or QOL between patients undergoing PR and SIS buttressed repair. There were no strictures, erosions, dysphagia, or other complications related to the use of SIS mesh.
LPEHR results in long and durable relief of symptoms and improvement in QOL with PR or SIS. There does not appear to be a higher rate of complications or side effects with biologic mesh, but its benefit in reducing HH recurrence diminishes at long-term follow-up (more than 5 years postoperatively) or earlier.
The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair.
Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms.
The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125).
The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.
Laparoscopic repair of paraesophageal hernia (PEH) involves removal of the hernia sac, cruroplasty, and fundoplication. Mesh application to cruroplasty seems to reduce hernia recurrence rate, but may be associated with dysphagia. The aim of the study was to review the clinical and laboratory outcomes of a series of patients with PEH after laparoscopic repair. Patients with PEH, who had laparoscopic repair and 1-year postoperative follow-up, were included in the study. Pre- and postoperative testing included symptom questionnaires, barium esophagogram, pH-monitoring, barium swallow testing. In the first half cases, suturing of large hernia gaps was reinforced with prosthesis (PR), whereas in the second half only suture cruroplasty (SC) was performed. Sixty-eight patients (36 male) with PEH were included in the study. There were no conversions to open. Postoperatively, dysphagia grading was significantly correlated to esophageal transit time (P < 0.001). There were seven recurrences; one paraesophageal and six wrap migrations. Also, four cases with stenosis were identified all in the PR group. Dysphagia was more common (P= 0.05) and esophageal transit more delayed (P= 0.034) after PR than after SC. Two revisions, one for esophageal stenosis and one for recurrent PEH, derived from the SC group. Reflux was more common after Toupet fundoplication than after Nissen fundoplication (NF) (P= 0.031) in patients with impaired esophageal motility. Laparoscopic repair of PEH with SC is associated with satisfactory clinical outcomes and low rate of wrap migration, at least similar to PR hiatal repair. NF is effective as an antireflux procedure in all cases.
Laparoscopic approach has been suggested as the definitive treatment for large hiatal hernias. Reinforcement of the hiatoplasty and the need to perform antireflux surgery is still undergoing discussion. The purpose of this study was to evaluate the postoperative results, with special emphasis on the recurrence rate and reflux after surgery comparing the use or not of mesh reinforcement. This prospective study included 81 patients with a complete evaluation through a clinical questionnaire, barium sulfate radiologic evaluation, endoscopy, manometry, and 24-hour intraesophageal pH monitoring before and after a hiatoplasty with an antireflux procedure. Mesh reinforcement was used in 23 patients. Postoperative complications occurred in 11 patients (13.6%), without mortality. Recurrent hernia was observed in 10 patients without mesh reinforcement (12.3%), whereas those with mesh reinforcement showed no hiatal hernia recurrence (P = 0.33). Normal resting lower esophageal sphincter pressure was obtained after fundoplication in 87.2% of patients, and abnormal acid reflux was observed in 12.8% of patients after surgery. In conclusion, mesh reinforcement in patients with large Type IV could prevent recurrent hiatal hernias, and an antireflux procedure must be performed in order to avoid postoperative acid reflux.
Primary laparoscopic hiatal hernia repair is associated with up to a 42% recurrence rate. This has lead to the use of mesh for crural repair, which has resulted in an improved recurrence rate (0-24%). However, mesh complications have been observed.
We compiled two cases, and our senior author contacted other experienced esophageal surgeons who provided 26 additional cases with mesh-related complications. Care was taken to retrieve technical operative details concerning mesh size and shape and implantation technique used.
Twenty-six patients underwent laparoscopic and two patients open surgery for large hiatal hernia (n = 28). Twenty-five patients had a concomitant Nissen fundoplication, two a Toupet fundoplication, and one a Watson fundoplication. Mesh types placed were polypropylene (n = 8), polytetrafluoroethylene (PTFE) (n = 12), biological mesh (n = 7), and dual mesh (n = 1). Presenting symptoms associated with mesh complications were dysphagia (n = 22), heartburn (n = 10), chest pain (n = 14), fever (n = 1), epigastric pain (n = 2), and weight loss (n = 4). Main reoperative findings were intraluminal mesh erosion (n = 17), esophageal stenosis (n = 6), and dense fibrosis (n = 5). Six patients required esophagectomy, two patients had partial gastrectomy, and 1 patient had total gastrectomy. Five patients did not require surgery. In this group one patient had mesh removal by endoscopy. There was no immediate postoperative mortality, however one patient has severe gastroparesis and five patients are dependent on tube feeding. Two patients died 3 months postoperatively of unknown cause. There is no apparent relationship between mesh type and configuration with the complications encountered.
Complications related to synthetic mesh placement at the esophageal hiatus are more common than previously reported. Multicenter prospective studies are needed to determine the best method and type of mesh for implantation.
The use of mesh for laparoscopic repair of large hiatal hernias may decrease recurrence rates in comparison with primary suture repair. The type of mesh material, as well as its size and shape, is still a matter of debate. The aim of this study was to evaluate a lightweight polypropylene mesh (TiMesh) repair of hiatal hernias, with particular reference to symptomatic relief, patient satisfaction and quality of life (QOL). From a prospectively maintained clinical database, 40 consecutive patients were identified who underwent elective laparoscopic hiatal hernia repair with TiMesh between November 2004 and December 2006. QOL and symptom analysis was carried out using Quality of Life in Reflux and Dyspepsia (QOLRAD) and dysphagia questionnaires preoperatively, and postoperatively after 6 weeks, 6 months, and 1 year. The mean age of the patient was 65.2 years (range: 40-93 years). Total complication rate was 7.5%; all complications were treated without residual disability. There was no 30-day mortality. Median hospital stay was 2.7 days (range 2-13 days). Completed questionnaires were obtained from 37 (92.5%) of 40 patients. After 1 year, more than 90% of patients were satisfied with their symptomatic outcome and regarded their surgery as successful. There was a significant improvement in QOL, measured with QOLRAD at all postoperative time-points (P < 0.001). There was no difference between pre- and postoperative dysphagia scores. Laparoscopic repair of large hiatal hernias with TiMesh yields good symptomatic and clinical outcome. Further studies are needed to show whether the use of this lightweight polypropylene mesh is associated with a reduction in recurrence rates after hiatal hernia repair in the longer term.
Twenty-seven patients underwent consecutive elective laparoscopic repair of paraesophageal hiatal hernia between October 1992 and June 1997. There were 24 females and 3 males. The average age was 68 years (range, 46-86) and average weight was 173 pounds (range, 122-243 lb.). Presenting symptoms were: postprandial epigastric pain or pressure in 19 patients, postprandial dyspnea in 7 patients, anemia in 5 patients, postprandial vomiting of food in 5 patients, and 1 patient had postprandial palpitation. Heartburn was present in 9 patients. Five patients had a history of symptoms of intermittent volvulus. History of hiatal hernia was present in 19 patients ranging from 6 months to 38 years in duration. The operative procedure included a laparoscopic reduction of the herniated stomach, excision of the hernia sac, and closure of the diaphragmatic defect with placement of mesh graft. Anterior gastropexy was performed on all patients except two who had a Nissen fundoplication due to severe reflux symptoms. Seven patients had laparoscopic cholecystectomy at the same time and one patient had an excision of a small benign gastric leiomyoma of the fundus. The average operative time was 2:54 hours (range, 1:35-4:05 hrs.). The average hospital stay was 3.8 days (range, 2-8 days). One patient had a postoperative stroke and recovered quickly. Follow-up of 1 to 56 months showed no recurrence of the hernia. Two patients complained of some epigastric pain and six patients had occasional mild reflux that was easily controlled medically. Laparoscopic repair of paraesophageal hernia is a safe procedure with a short hospital stay and recovery time. Using mesh graft decreases the risk of developing an iatrogenic parahiatal hernia. The addition of Nissen fundoplication is not necessary unless the patient has objective findings of reflux.
Laparoscopic repair of large hiatal hernia is an appropriate management strategy.
A prospective patient series.
A university teaching hospital.
All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998.
Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus.
Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome.
Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%).
Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.
We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients.
Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times.
In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series.
Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative.
We wished to evaluate the long-term effectiveness of the laparoscopic Hill repair in the treatment of type III hiatal hernia. Fifty-two patients underwent laparoscopic repair of a type III hiatal hernia. No esophageal lengthening procedures were performed. Short esophagus was determined from the operative record. Late symptomatic follow-up and a satisfaction questionnaire were completed in 71% (37/52) of patients at a mean of 39 months (range 6 to 84 months). Esophagrams were completed in 65% (34/52) of patients at a mean of 37 months (range to 84 months) after repair. Eighty-one percent were without any adverse symptoms, and 86% rated outcome as excellent or good at 39 months. Symptoms requiring treatment were present in 19% (7/37). Esophagrams revealed a recurrent hernia in 32% (11/34) of patients of whom 36% (4/11) were asymptomatic. Six patients with short esophagus underwent esophagram with one recurrence identified (17%). This was compared with 28 patients without short esophagus, of whom 10 had a recurrence (35%) (P = 0.70). The laparoscopic Hill repair provides long-term satisfaction and relief of symptoms. The incidence of anatomic recurrence on video esophagram is high and does not always correlate with symptoms. The presence of short esophagus does not play a role in recurrence when the Hill repair is used.
To examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias.
The management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery.
A Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted life-years (QALYs).
Analysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery.
If ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.
Previous studies have shown that surgical repair of paraesophageal hernias is associated with a high recurrence rate, especially when a laparoscopic approach is used. Anatomic recurrence due to crura breakdown is a primary etiology, which has led us to employ prosthetic mesh reinforcement of large hiatal defects (> 5 cm) since 1996. We discuss the evolution of this approach and describe our current technique with limited outcomes in 52 consecutive patients during a 5-year period.
There were 31 males and 21 females, with a mean age of 57 years (range, 32-77 years) with symptomatic reflux and endoscopic or radiologic evidence of a large paraesophageal hernia. Utilizing a laparoscopic approach, the contents of the sac were reduced and the crura approximated with permanent interrupted sutures and a prosthetic mesh was secured over the repair as an on-lay reinforcement buttress. A Nissen (42) or Tilley (9) fundoplication was performed in all but 1 patient, and 18 patients (34%) required a wedge collis gastroplasty. Fifteen patients (28%) had a previous unsuccessful antireflux operation.
There was no perioperative morbidity or mortality. Follow-up averaged 25 months (range, 7-60 months). Postoperative gastroscopy or barium swallow have been performed in 27 patients to date, with 11 experiencing foregut symptoms. There has been 1 recurrence (1.9%) and no prosthetic erosion.
Early results suggest that prosthetic mesh cruroplasty may be effective in reducing recurrence after laparoscopic repair of large paraesophageal hernias, but long-term follow-up is required in all patients to determine the true incidence of anatomic recurrence and prosthetic erosion.
Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus.
Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure.
Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death.
Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.
Laparoscopic repair of large paraesophageal hiatal hernias is associated with several areas of contention. One of these is primary repair of the esophageal hiatus versus repair with the use of a prosthetic mesh material. Those who favor primary repair are concerned because of the risk of erosion of the prosthesis into surrounding viscera. Those who favor hiatal closure with the aid of a prosthetic mesh are concerned because of the relatively high rate of reherniation of the repair. A biodegradable mesh composed of small intestinal submucosa (SIS ES Cook Surgical, Bloomington, IN) may resolve the concerns of the opposing points of view. It has been shown in animal studies to maintain strength while it is gradually resorbed and replaced by native host tissue. Since April of 2000, 12 (8 female, 4 male) patients have had laparoscopic repair of large paraesophageal hiatal hernias with hiatal closure accomplished with this material. Nine of these 12 patients have had barium studies at six months post-procedure and seven at one year. No failures demonstrated.
Because of the risk of life-threatening complications, the discovery of a complete intrathoracic stomach demands urgent surgery with the aim of repositioning the stomach and gastropexy, and secondarily, to improve life quality. In this study the feasibility of surgical technique and postoperative quality of life after laparoscopic treatment of complete intrathoracic stomach has been evaluated.
From June 1999 to December 2001 16 patients with an intrathoracic stomach (hiatus hernia Types IIB and III) were treated by laparoscopic techniques, including the repositioning of the stomach, hemi-fundoplication and anterior gastropexy. During the postoperative follow-up the recurrence rate and quality of life (Eypasch index) were evaluated.
All operations were performed laparoscopically without conversion, with a mean operating time of 155 min. Pleural injuries occurred in 31% of patients and pleural effusions in 38%, which required puncture in three cases. Complete follow-up showed no recurrences at a median of 14 months. The median quality of life index was 84.6 preoperatively and had significantly improved to 117.8 after the operation.
Laparoscopic access for the treatment of intrathoracic stomach represents a minimally invasive and safe treatment option for complete intrathoracic stomach, with a low level of perioperative morbidity and significant improvement in quality of life.
To analyze the experience acquired to date on the use of prosthetic mesh to prevent recurrence after laparoscopic repair of paraesophageal hernia.
Current English-language literature review.
Case reports, series, and opinion articles on the use of mesh for paraesophageal hernia repair.
Study type and results were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the procedure have been published to date. The information available showed that the use of a mesh for hiatal repair was safe and prevented recurrence. However, data on the long-term results were lacking, and infrequent but severe complications may arise.
The mesh should be used selectively, and the decision to proceed should be based on clinical experience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have not been confirmed.
Surgical repair of large hiatal hernias is associated with a high recurrence rate when the repair is made by simple cruroplasty. The use of a mesh goes from a reinforcement of a simple cruroplasty to a tension-free repair. We discuss the evolution of this approach and evaluate the outcomes of 27 patients with type II (n = 9), type III (n = 16), and type IV (n = 2) hiatal hernias treated laparoscopically.
Between November 1999 and October 2003, 27 patients (18 women and 9 men) received laparoscopic repair of large hiatal hernias by means of an A-shaped polypropylene-polytetrafluoroethylene mesh. A total or a partial fundoplication was associated in all cases. The mean age was 60.1 years (range, 36-76 years). The patients presented with symptoms of 2 months to 10 years in duration. Preoperative assessment included an upper gastrointestinal endoscopy, esophageal manometry, 24 hour pH monitoring, and barium swallow. Concomitant esophagitis was found in 16 patients and impaired esophageal peristalsis in 2 patients. Four patients had concomitant gallbladder disease treated at the same time.
No conversions occurred in our series. There was no perioperative mortality, and morbidity was low. Follow-up averaged 27 months (range, 6-46 months). There has been 1 recurrence (3.7%), prolonged dysphagia in 4 cases, and no mesh erosion.
Early results confirm the feasibility of the tension-free repair of large hiatal hernias and the effectiveness of the composite A-shaped mesh. Long-term follow-up for all patients is necessary to determine the real incidence of recurrence.
Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence.
A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both.
Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract.
The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.
Laparoscopic paraesophageal hernia repair (LPEHR) is associated with a high recurrence rate. Repair with synthetic mesh lowers recurrence but can cause dysphagia and visceral erosions. This trial was designed to study the value of a biologic prosthesis, small intestinal submucosa (SIS), in LPEHR.
Patients undergoing LPEHR (n = 108) at 4 institutions were randomized to primary repair -1 degrees (n = 57) or primary repair buttressed with SIS (n = 51) using a standardized technique. The primary outcome measure was evidence of recurrent hernia (> or =2 cm) on UGI, read by a study radiologist blinded to the randomization status, 6 months after operation.
At 6 months, 99 (93%) patients completed clinical symptomatic follow-up and 95 (90%) patients had an UGI. The groups had similar clinical presentations (symptom profile, quality of life, type and size of hernia, esophageal length, and BMI). Operative times (SIS 202 minutes vs. 1 degrees 183 minutes, P = 0.15) and perioperative complications did not differ. There were no operations for recurrent hernia nor mesh-related complications. At 6 months, 4 patients (9%) developed a recurrent hernia >2 cm in the SIS group and 12 patients (24%) in the 1 degrees group (P = 0.04). Both groups experienced a significant reduction in all measured symptoms (heartburn, regurgitation, dysphagia, chest pain, early satiety, and postprandial pain) and improved QOL (SF-36) after operation. There was no difference between groups in either pre or postoperative symptom severity. Patients with a recurrent hernia had more chest pain (2.7 vs. 1.0, P = 0.03) and early satiety (2.8 vs. 1.3, P = 0.02) and worse physical functioning (63 vs. 72, P = 0.03 per SF-36).
Adding a biologic prosthesis during LPEHR reduces the likelihood of recurrence at 6 months, without mesh-related complications or side effects.
Many studies have confirmed the effectiveness of laparoscopic paraesophageal hernia repair, but there are reports of high recurrence rates after surgery. We have conducted a review of the literature to determine whether it is a safe and durable procedure. A literature search was performed to identify all papers relevant to laparoscopic paraesophageal hernia repair. Twenty studies met the inclusion criteria for this review. In total, 1415 patients underwent attempted repair (mean age 65.7 y) of which 94% underwent an antireflux procedure. There were 70 (5.3%) episodes of operative morbidity and 173 (12.7%) patients experienced postoperative complications. In 10 studies, radiologic follow-up was offered after a mean of 16.5 months. Of those undergoing contrast swallow 26.9% had evidence of anatomic recurrence. In conclusion, recurrence rates after laparoscopic repair seem to be high compared with earlier studies of open repair. The long-term consequences of anatomic recurrence are currently uncertain.
Recent reports suggest that when laparoscopy is used to repair paraesophageal hernias recurrence rates reach 20% to 40%. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in esophageal injury. We hypothesized that reinforcement of the hiatal closure with small intestine submucosa (SIS) mesh, in some unusually large hernias, might reduce recurrence rates without causing injury to the esophagus.
From January 2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic approach. In 9 of the largest hernias (one type II and 8 type III, of which 1 was recurrent) the repair was reinforced with SIS mesh (Surgisis, Cook Surgical) and represent the subjects of this study. Nissen fundoplication with gastropexy was performed in all patients. Clinical follow-up ranged from 3 to 16 months (median 8). Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8 months (median 2) postoperatively.
The presenting symptoms were postprandial pain/fullness (9 of 9), heartburn (4 of 9), anemia (4 of 9), dysphagia (3 of 9), regurgitation (3 of 9), and chest pain (3 of 9). One patient died of a hemorrhagic stroke within 30 days of the operation. Postoperatively, presenting symptoms resolved (83%) or improved (17%) in each of the remaining 8 patients. One patient required endoscopic dilation for mild dysphagia. Seven of 8 patients had a normal barium esophagram without evidence of hernia. One morbidly obese (body mass index = 47) patient had a small (2 cm) sliding hiatal hernia postoperatively. There were no other complications, and specifically no perforations or mesh erosions.
These observations suggest that the use of SIS in the repair of paraesophageal hernias is safe and may reduce recurrence. Longer follow-up and a randomized study are needed to validate these results.
Background:
The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophgeal reflux disease. However, it is recognized that recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. Some have described a reduction of such events with the placement of nonbiodegradable prosthetic patches over the primary cruroplasty. This prosthetic material may be associated with transesophageal and gastric erosions and a higher rate of postoperative dysphagia and chest pain when compared with simple suture cruroplasty alone. The aim of this study is to compare hiatal closure with a biodegradable patch (acellular dermal matrix) and simple suture curaplasty in patients undergoing laparoscopic antireflux surgery.
Methods:
A total of 44 patients were prospectively enrolled in this study. Twenty-two consecutive patients undergoing large hiatal hernia repair (>5 cm) and fundoplication with primary suture cruroplasty only (group 1) were compared with 22 consecutive patients undergoing the same procedure with suture cruroplasty reinforced with an onlay acellular dermal matrix patch (group 2). The 2 groups were compared with regards to demographics, size of the hiatal hernia, pre- and postoperative symptom scores, pH studies, operative times, and hiatal hernia recurrence.
Results:
Patients in both groups were well matched by age, weight, height, and size of hiatal hernia. There were similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring in both groups. Average operative time was 108 minutes in group 1 and 121 minutes in group 2. There were no major complications in either group. The median period of hospitalization was 1 day in both groups. Postoperative pH studies and symptoms score data were significantly improved in both groups. There was no significant difference in postoperative symptoms scores for dysphagia between the 2 groups. Two patients (one in each group) underwent esophageal dilatation for mild dysphagia postoperatively. In group 1, 2 patients (9%) had Nissen failure with hiatal hernia recurrences 6 months after surgery. There were no recurrences for the follow-up period in group 2.
Conclusions:
Our early results suggest that hiatal hernia repair reinforced with an acellular dermal matrix patch may reduce the incidence of recurrent herniation and wrap migration. In addition, the increase in postoperative dysphagia, chest pain, and esophageal erosions associated with nondegradable mesh has not been observed in those with an acellular dermal matrix patch to this point in our follow up. However, future investigation of the material for this particular application as well as longer follow-up is necessary.
Biologic prosthetics may circumvent mesh-related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH).
Records of 17 patients who underwent laparoscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6-12 months after surgery. (Data are presented as mean +/- standard deviation.)
Mean patient age was 65 +/- 12 years and BMI was 31 +/- 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 +/- 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 +/- 48 min. Average hiatal defect size was 4.7 x 2.7 cm, with 4.2 +/- 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 +/- 0.8 days. Mean followup was 14.4 +/- 4.4 months. Postoperatively, only one (6%) patient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 +/- 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled buttress site.
Acellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach.
Symptomatic results of laparoscopic repair of large type III hiatal hernias, with/without prosthetic mesh, are often excellent; however, a high recurrence rate is detected when objective radiological/endoscopic follow-up is performed. The use of mesh may reduce the incidence of postoperative hernia recurrence or wrap migration in the chest.
We retrospectively studied 54 patients (10 men, 44 women; median: age 64.5 years) with a diagnosis of large type III hiatal hernia (>1/3 stomach in the chest on x-ray) who underwent laparoscopic repair at our department from January 1992 to June 2005. Complications, recurrences, and symptomatic and objective (radiological/endoscopic) long-term outcome were evaluated.
Nineteen patients had laparoscopic Nissen/Toupet fundoplication with simple suture; in 35 patients a double mesh was added. The median radiological/endoscopic follow-up was 64 months (interquartile range (IQR): 6-104) for the non-mesh group and 33 (IQR:12-61) for the mesh group (p = 0.26). Recurrences occurred in 11/54 (20%) patients: 8/19 (42.1%) without mesh and 3/35 (8.6%) with mesh (p = 0.01). The 3 recurrences in the mesh group all occurred < or =12 months postoperatively; 4/8 recurrences in the non-mesh group occurred > or =5 years after operation. On multivariate logistic regression analysis, only mesh absence significantly predicted hernia recurrence or wrap migration.
Laparoscopic repair of large type III hiatal hernias is safe and effective. Short-term symptomatic results are excellent, but mid-term objective radiological/endoscopic evaluation reveals a high recurrence rate. Possible reasons for failure of a laparoscopic hiatal repair are tension or poor muscle tissue characteristics in the hiatus. The use of a mesh, either by reducing tension or reinforcing muscle at the hiatus, might be associated with a lower recurrence rate. Longer-term follow-up will be needed before definitive conclusions can be drawn, however.
Laparoscopic repair of a large hiatal hernia using simple sutures only for the cruroplasty is associated with a high recurrence rate. The solution was to place synthetic mesh over the cruroplasty thereby decreasing recurrence rates in exchange for complications, such as gastric and esophageal erosions. Our initial report investigated the use of human acellular dermal matrix (AlloDerm) as a more suitable alternative. This study highlights our long-term results>1 year of cruroplasty reinforcement with AlloDerm in the repair of large hiatal hernias.
This is a retrospective study performed at our university. Between 2005 and 2006, 52 consecutive patients with large hiatal hernias had the cruroplasty site reinforced with AlloDerm. The variables analyzed were age, sex, weight, height, hiatal hernia size, operative time, length of hospital stay, follow-up, and postoperative complications.
The mean for age was 56.7 years, for weight was 87.9 kg, for height 117 cm, for hernia size was 5.75 cm, operative time was 121 min, and for hospital stay was 1.36 days. Complication included pneumothorax, 3 (5.5%); atelectasis, 1 (1.9%); urinary retention, 1 (1.9%); and recurrence, 2 (3.8%).
Laparoscopic hiatal hernia repair with reinforcement using human acellular dermal matrix can be performed safely with a short hospital stay and low rate of complications, especially a low rate of recurrence.