Laparoscopic Prosthetic Reinforcement of Hiatal Herniorrhaphy

Abstract

Background/Aims: 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. Methods: 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. Results: 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, χ² test). Conclusion: 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.

Evidence-Based Appraisal of Antireflux Fundoplication

“…56,62 The rates of hiatal hernia recurrence after hiatal repair during primary laparoscopic fundoplication vary between 1 and 7%, but can reach 50% when facing large and/or paraesophageal hernias. There was little doubt that any repair of large hernias should be performed with a prosthetic reinforcement, 109 and the results of one RCT 69,70 seem to confirm this concept, with 5 patients to be treated to avoid 1 hernia recurrence (Table 10). Further research is needed to find which cut-off in hiatal hernia size mandates a prosthetic repair.…”

Uso de próteses na correção cirúrgica das hérnias hiatais

“…In addition to preoperative evaluation complete with correct diagnosis and an experienced surgeon, to improve the performance of the surgical procedure some technical aspects of HPLC should be followed to reduce postoperative complications. There is a general consensus among surgeons that the hiatal closure should be done routinely, regardless of whether or not a hiatal hernia 5,18,23,24,27 . Granderath, et al…”

“…Some researchers have suggested that the use of prostheses in strengthening the hiatal crura has proven to be a protective factor for the presence of recurrent hiatal hernia or slip of the fundoplication into the chest 9,22 . The reinforcement of the prosthesis for hiatal hernia repair has been successfully used by Carlson, et al 5 . In a randomized study with 31 patients, laparoscopic primary repair of large hiatal hernias was compared with laparoscopic primary repair reinforced with fabric of polytetrafluoroethylene (PTFE).…”

Laparoscopic management of large hiatus hernia with mesh cruroplasty

“…The most commonly used mesh is polypropylene (Prolene; Ethicon, Inc., Somerville, NJ, USA) [11][12][13]. Several different types of polytetrafl uroethylene (PTFE) and composite materials have been used including dual mesh (W.L Gore and associates, Inc., Flagstaff, AZ, USA) [14] and a simple PTFE patch [15,16]. Porcine small intestinal mucosa (Surgisis; Cook surgical, Bloomington, IN, USA), which provides scaffolding for natural tissue ingrowth, also is used [17].…”