New Surgical Approach for Giant Paraesophageal Hernia Repair: Closure of the Esophageal Hiatus Anteriorly Using the Left Triangular Ligament

Abstract

Background: Obtaining a tension-free repair for giant paraesophageal hernias (PEH) is often challenging. Many different techniques have been proposed, including laparoscopic posterior hiatoplasty with the use of prosthetic or biologic mesh as well as the use of autologous teres or falciform ligament flaps. In this report, we describe the use of the left triangular ligament as an onlay autologous vascularized flap to bridge the anterior residual defect after posterior cruroplasty. Methods: A novel technique of paraesophageal hiatal hernia repair is described. Posterior hiatoplasty is performed, including the approximation of the diaphragmatic crural fibers to the extent possible. The left triangular ligament is then mobilized and sutured to the right and left crural fibers lining the esophageal hiatus to seal the anterior residual diaphragmatic defect. Results: This technique has been performed in 4 patients with a mean age of 71 years and a 3:1 female to male ratio. The average hiatal defect size was 5.5 cm and the average length of operation was 122 min. There was no evidence of radiologic or clinical recurrence on follow-up. Conclusion: The use of the left triangular ligament flap is feasible and may be a valuable tool for closure of an anterior diaphragmatic defect in giant PEHs. Additional studies to validate its long-term function are needed.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis

“…31,32 Autologous biological tissue has been used to buttress the hiatus in nonbariatric scenarios. [33][34][35] The primary aim of this metaanalysis was to evaluate the safety and efficacy of LTA to buttress the repair of HH and treat GERD in the management of patients who previously underwent MBS. Based on 5 studies within this meta-analysis, more than three-quarters of patients experienced complete resolution of their GERD symptoms and reduction of PPI use at the long-term followup.…”

“…HH and symptomatic GERD are frequent long-term issues encountered after MBS, but the optimal surgical solution for them has yet to be agreed upon 31,32 . Autologous biological tissue has been used to buttress the hiatus in non-bariatric scenarios 33–35 . The primary aim of this meta-analysis was to evaluate the safety and efficacy of LTA to buttress the repair of HH and treat GERD in the management of patients who previously underwent MBS.…”

One More Time: Redo Paraesophageal Hernia Repair Results in Safe, Durable Outcomes Compared with Primary Repairs

“…6 More recently, use of falciform or triangular ligaments to support crural closures has been described. 20,21…”