Giant hiatal hernias: direct hiatus closure has an acceptable recurrence rate

Abstract

The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia

“…A number of authors [65,66] have reported an incidence of reflux symptoms in up to 47% of patients whose repair did not include any kind of fundoplication. It has been suggested that a fundoplication might reduce the recurrence rate by fixing the stomach in the abdomen, but this has not been demonstrated prospectively [10]. We performed an antireflux procedure in all the cases with a good control of reflux symptoms.…”

“…This condition, therefore, is a prerequisite for a successful treatment. At this time, the decision to carry out a mesh cruroplasty rather than a direct closure after repairing a hiatal hernia is based on personal experience, and additional randomized studies on standardized use of reinforcement procedures are needed [10]. Another often discussed issue concerns the need for antireflux surgery in hiatal hernia repair.…”

“…Another often discussed issue concerns the need for antireflux surgery in hiatal hernia repair. The extensive dissection required to obtain a quite long esophageal segment in the abdomen can make the gastroesophageal junction fail, resulting in postoperative reflux symptoms [10]. A number of authors [65,66] have reported an incidence of reflux symptoms in up to 47% of patients whose repair did not include any kind of fundoplication.…”

“…Gastric strangulation, acute massive bleeding and perforation are rare but severe complications that may be found in emergency [5,8,9]. For this anatomical disruption the medical options are not adequate, therefore the surgical therapeutic strategy represents the only way to return to the past, to relieve the symptoms as well as to avoid serious complications [10]. In the past repair of giant hiatal hernia in open surgery (simple reduction, resection of the sac, gastropexy, and several types of fundoplication), transthoracically or transabdominally, is often considered the last chance for patients, above all for associated significant morbidities, mortalities, surgical pain and length of hospitalization [11-14].…”

Laparoscopic surgery of esophageal hiatus hernia – single center experience

“…Total excision of the hernial sac reduces risk of recurrence. According to the analyzed data, synthetic meshes do not reduce the risk of hernia recurrence [15]. Hernia recurrence is sometimes accompanied by migration of the gastric cuff to the mediastinum.…”