Laparoscopic repair of hiatal hernias: new classification supported by long-term results

Discrepancies in the Reporting of Hiatal Hernia Size: A Review

BackgroundIn the current literature there is a paucity of both standardized diagnostic criteria and accurate methods for determining hernia size. The aim of this review is to describe the most common methods for reporting hiatal hernia size.MethodsLiterature search using PubMed and Embase databases was performed. After exclusion and screening, 67 articles were analyzed and data were collected on hernia type and subtype, diagnostic method, size reporting method, and the author's definition of hernia size (measurement protocol).ResultsAuthors publishing on hiatal hernia size employed 8 different methods for diagnosing hiatal hernias and reported data using 7 distinct measurement types. Within individual diagnostic methods there was a further lack of standardization of measurement protocols.ConclusionOur review underscores the critical need for standardized reporting methods in the assessment and reporting of hiatal hernia size. Moving forward, collaboration is essential to establish and adopt standardized guidelines for reporting hiatal hernia size, ultimately improving patient care and outcomes.

Postoperative obstruction of recurrent esophageal hiatal hernia: A case report

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.

Surgical strategies for recurrent hiatal hernia: three-point fundoplication fixation

BACKGROUND

The management of a recurrent (symptomatic) hiatal hernia remains controversial. This study aimed to review the outcomes of patients who underwent recurrent repair of hiatal hernias.

METHODS

Thirteen patients who underwent recurrent hiatal hernia repairs at our hospital between 2018 and 2024 were reviewed retrospectively. The postoperative outcomes and complications of these patients were investigated.

RESULTS

Thirteen patients were included in this study. The median time of reoperation from the previous hiatal hernia repair was 3 years (IQR, 2.5-5). Patients with a history of only one repair accounted for 76.9%, whereas those with two repairs accounted for 23.1%. All reoperations were completed laparoscopically. No deaths or readmissions during the 30-day postoperative period were recorded at an average of 30.5 ± 20.9 (6-68) months of follow-up. No other complications or symptoms were recorded, and oral medication was discontinued in eleven (84.6%) patients. The average GERD-Q score was 6.7 ± 1.3 postoperatively, whereas it was 10.4 ± 3.0 preoperatively.

CONCLUSION

We present several surgical strategies for addressing the recurrence of hiatal hernias. The key is not only to accurately close the hernia ring but also to fix the fundoplication to reduce the impact on the tissue around the hiatus to reduce the incidence of recurrence. Our three-point fixation technique showed promising effects in preventing recurrence but needs further study.

CLINICAL TRIAL NUMBER

ChiCTR2100049995.

The classification of hiatal shapes and their use as a marker for complexity, operative interventions, and recurrence

BACKGROUND

Diaphragmatic reconstruction is a vital, but challenging component of hiatal hernia and antireflux surgery. Results are optimized by minimizing axial tension along the esophagus, assessed with intra-abdominal length, and radial tension across the hiatus, which has not been standardized. We categorized hiatal openings into 4 shapes, as a surrogate for radial tension, to correlate their association with operative interventions and recurrence.

METHODS

We retrospectively reviewed all primary hiatal hernias (≥3 cm) repaired at a single center between 2010 and 2020. Patients with intraoperative hiatal photos with at least 1 year of follow-up were included. The hiatal openings were classified into 4 shapes: slit, inverted teardrop, "D," and oval, and ordered in this manner of hypothesized increased complexity and tension.

RESULTS

A total of 239 patients were studied, with 113 (47%) having a recurrence. Age (P < .001), proportion of paraesophageal hernias (P < .001), hernia axial length (P < .001), and hiatal width (P < .001) all increased as shape progressed from slit to inverted teardrop to "D" to oval. Mesh (P = .003) and relaxing incisions (P < .001) were more commonly employed in more advanced shapes, "D" and ovals. However, recurrence (P = .88) did not correlate with hiatal shape.

CONCLUSION

Four different hiatal shapes are commonly seen during hernia repair. These shapes represent a spectrum of hernia chronicity and complexity necessitating increased use of operative measures but not correlating with recurrence. Despite failing to be a direct marker for recurrence risk, hiatal shape may serve as an intraoperative tool to inform surgeons of the potential need for additional hiatal interventions.

Hiatal Hernias Revisited-A Systematic Review of Definitions, Classifications, and Applications

INTRODUCTION

A hiatal hernia (HH) can be defined as a condition in which elements from the abdominal cavity herniate through the oesophageal hiatus in the mediastinum and, in the majority of cases, parts of the proximal stomach. Today, the role of HHs within the complex entity of gastroesophageal reflux disease (GERD) is very important with regard to its pathophysiology, severity, and therapeutic and prognostic options. Despite this, the application and stringent use of the worldwide accepted classification (Skinner and Belsey: Types I-IV) are lacking. The aim of this study was to carry out a systematic review of the clinical applications of HH classifications and scientific documentation over time, considering their value in diagnosis and treatment.

METHODS

Following the PRISMA concept, all abstracts published on pubmed.gov until 12/2023 (hiatal hernia) were reviewed, and those with a focus and clear description of the application of the current HH classification in the full-text version were analysed to determine the level of classification and its use within the therapeutic context.

RESULTS

In total, 9342 abstracts were screened. In 9199 of the abstracts, the reports had a different focus than HH, or the HH classification was not used or was incompletely applied. After further investigation, 60 papers were used for a detailed analysis, which included more than 12,000 patient datapoints. Among the 8904 patients, 83% had a Type I HH; 4% had Type II; 11% had Type III; and 1% had Type IV. Further subgroup analyses were performed. Overall, the precise application of the HH classification has been insufficient, considering that only 1% of all papers and only 54% of those with a special focus on HH have documented its use.

CONCLUSIONS

The application and documentation of a precise HH classification in clinical practice and scientific reports are decreasing, which should be rectified for the purpose of scientific comparability.

BRAZILIAN HERNIA AND ABDOMINAL WALL SOCIETY STATEMENT ON LARGE HIATAL HERNIAS MANAGEMENT

Large hiatal hernias, besides being more prevalent in the elderly, have a different clinical presentation: less reflux, more mechanical symptoms, and a greater possibility of acute, life-threatening complications such as gastric volvulus, ischemia, and visceral mediastinal perforation. Thus, surgical indications are distinct from gastroesophageal reflux disease-related sliding hiatal hernias. Heartburn tends to be less intense, while symptoms of chest pain, cough, discomfort, and tiredness are reported more frequently. Complaints of vomiting and dysphagia may suggest the presence of associated gastric volvulus. Signs of iron deficiency and anemia are found. Surgical indication is still controversial and was previously based on high mortality reported in emergency surgeries for gastric volvulus. Postoperative mortality is especially related to three factors: body mass index above 35, age over 70 years, and the presence of comorbidities. Minimally invasive elective surgery should be offered to symptomatic individuals with good or reasonable performance status, regardless of age group. In asymptomatic and oligosymptomatic patients, besides obviously identifying the patient's desire, a case-by-case analysis of surgical risk factors such as age, obesity, and comorbidities should be taken into consideration. Attention should also be paid to situations with greater technical difficulty and risks of acute migration due to increased abdominal pressure (abdominoplasty, manual labor, spastic diseases). Technical alternatives such as partial fundoplication and anterior gastropexy can be considered. We emphasize the importance of performing surgical procedures in cases of large hiatal hernias in high-volume centers, with experienced surgeons.

Recurrence in Paraesophageal Hernia: Patient Factors and Composite Surgical Repair in 862 Cases

BACKGROUND

Repair of giant paraesophageal hernia (PEH) is associated with a considerable hernia recurrence rate by objective measures. This study analyzed a large series of laparoscopic giant PEH repair to determine factors associated with anatomical recurrence.

METHOD

Data was extracted from a single-surgeon prospective database of laparoscopic repair of giant PEH from 1991 to 2021. Upper endoscopy was performed within 12 months postoperatively and selectively thereafter. Any supra-diaphragmatic stomach was defined as anatomical recurrence. Patient and hernia characteristics and technical operative factors, including "composite repair" (360° fundoplication with esophagopexy and cardiopexy to right crus), were evaluated with univariate and multivariate analysis.

RESULTS

Laparoscopic primary repair was performed in 862 patients. The anatomical recurrence rate was 27.3% with median follow-up of 33 months (IQR 16, 68). Recurrence was symptomatic in 45% of cases and 29% of these underwent a revision operation. Hernia recurrence was associated with younger age, adversely affected quality of life, and were associated with non-composite repair. Multivariate analysis identified age < 70 years, presence of Barrett's esophagus, absence of "composite repair", and hiatus closure under tension as independent factors associated with recurrence (HR 1.27, 95%CI 0.88-1.82, p = 0.01; HR 1.58, 95%CI 1.12-2.23, p = 0.009; HR 1.72, 95%CI 1.2-2.44, p = 0.002; HR 2.05, 95%CI 1.33-3.17, p = 0.001, respectively).

CONCLUSION

Repair of giant PEH is associated with substantial anatomical recurrence associated with patient and technique factors. Patient factors included age < 70 years, Barrett's esophagus, and hiatus tension. "Composite repair" was associated with lower recurrence rate.

Measurement of oesophageal hiatus surface area by multiplanar reconstruction of MDCT: relationship with lower oesophageal sphincter pressure and acid reflux

AIM

To evaluate the relationship between oesophageal hiatus surface area (OHSA) and gastro-oesophageal reflux disease (GERD).

MATERIALS AND METHODS

Patients who underwent 24-h pH monitoring, oesophageal high-resolution manometry, and upper abdominal contrast-enhanced multidetector computed tomography (MDCT) during 2014-2021 were enrolled. Patients with a hiatus hernia (HH) on MDCT or who had a history of gastro-oesophageal surgery were excluded. Multiplanar reconstruction (MPR) of the MDCT image was used for the measurement of OHSA. Correlations of OHSA with acid exposure time (AET) and lower oesophageal sphincter (LOS) pressure of all patients were analysed.

RESULTS

Seventy-eight patients were included in the study. OHSA was much less in the AET <4% group than in the AET >6% group (1.61 ± 0.42 versus 2.09 ± 0.55 cm2, p<0.001). Correlation analysis reveals that OHSA correlated positively with AET (correlation coefficient = 0.47, p<0.001). Receiver operating characteristic (ROC) curve analysis reveals that OHSA can significantly distinguish patients in different groups divided by AET (area under the ROC curve [AUC] = 0.76, 95% confidence interval [CI]: 0.63-0.90). OHSA was not related to LOS pressure (correlation coefficient = -0.268, p=0.051). There was no difference in OHSA between the low LOS pressure group and the normal LOS pressure group (1.84 ± 0.61 versus 1.74 ± 0.50 cm2, p=0.52).

CONCLUSIONS

OHSA significantly correlated with AET but has no relationship with LOS pressure. It may be an independent risk factor of GERD.

Laparoscopic large hiatus hernia repair with mesh reinforcement versus suture cruroplasty alone: a systematic review and meta-analysis

BACKGROUND

To compare the difference in outcomes in laparoscopic large hiatus hernia (LHH) repair using suture-based and mesh-based repair techniques.

METHODS

A systematic search of articles was conducted in PubMed, Medline and Embase using the PRISMA guidelines. Studies comparing recurrences and reoperations in those patients with large hiatal hernia repair (> 30% stomach in the chest, > 5 cm hiatal defect, hiatal surface area > 10 cm²) who had mesh vs no mesh were assessed quantitatively. The impact of mesh on significant intraoperative/postoperative surgical complications was qualitatively assessed.

RESULTS

Pooled data included six randomized controlled trials and thirteen observational studies with 1670 patients (824 with no mesh, 846 with mesh). There was a significant reduction in the total recurrence rate with mesh (OR 0.44, 95% CI 0.25-0.80, p = 0.007). Mesh use did not cause significant reduction in recurrences > 2 cm (OR 0.94, 95% CI 0.52-1.67, p = 0.83) or in reoperation rates (OR 0.64, 95% CI 0.39-1.07, p = 0.09). None of the specific meshes assessed were found to be superior in the reduction of recurrence or reoperation rates. Cases of mesh erosion with eventual foregut resection were noted and were associated with synthetic meshes only.

CONCLUSION

Mesh reinforcement seemed protective against total recurrence in LHH although this has to be interpreted with caution given the level of heterogeneity introduced by the inclusion of observational studies in the analysis. There was no significant reduction in large recurrences (> 2 cm) or reoperation rate. If the synthetic mesh is to be used patients need to be informed of the risk of mesh erosion.

Large hiatus hernia: time for a paradigm shift?

Background

Laparoscopic large hiatal hernia (LHH) repair remains a challenge despite three decades of ongoing attempts at improving surgical outcome. Its rarity and complexity, coupled with suboptimal initial approach that is usually best suited for small symptomatic herniae have contributed to unacceptable higher failure rates.

Results

We have therefore undertaken a systematic appraisal of LHH with a view to clear out our misunderstandings of this entity and to address dogmatic practices that may have contributed to poor outcomes.

Conclusions

First, we propose strict criteria to define nomenclature in LHH and discuss ways of subcategorising them. Next, we discuss preoperative workup strategies, paying particular attention to any relevant often atypical symptoms, indications for surgery, timing of surgery, role of surgery in the elderly and emphasizing the key role of a preoperative CT imaging in evaluating the mediastinum. Some key dissection methods are then discussed with respect to approach to the mediastinal sac, techniques to avoid/deal with pleural breach and rationale to avoid Collis gastroplasty. The issues pertaining to the repair phase are also discussed by evaluating the merits of the cruroplasty, fundoplication types and gastropexy. We end up debating the role of mesh reinforcement and assess the evidence with regards to recurrence, reoperation rate, complications, esophageal dilatation, delayed gastric emptying and mortality. Lastly, we propose a rationale for routine postoperative investigations.

Patient-tailored algorithm for laparoscopic cruroplasty standardization: comparison with hiatal surface area and medium-term outcomes

BACKGROUND

Different methods have been described for laparoscopic hiatoplasty and hiatus hernia (HH) repair. All techniques are not standardized and the choice to reinforce or not the hiatus with a mesh is left to the operating surgeon's preference. Hiatal surface area (HSA) has been described as an attempt at standardization; in case the area is > 4 cm², a mesh is used to reinforce the repair.

OBJECTIVE

The aim of this study was to describe a new patient-tailored algorithm (PTA), compare its performance in predicting crura mesh buttressing to HSA, and analyze outcomes.

METHODS

Retrospective, single-center, descriptive study (September 2018-September 2021). Adult patients (≥ 18 years old) who underwent laparoscopic HH repair. Outcomes and quality of life measured with the disease-specific gastroesophageal reflux disease health-related quality of life (GERD-HRQL) and reflux symptom index (RSI) were analyzed.

RESULTS

Fifty patients that underwent laparoscopic hiatoplasty and Toupet fundoplication were included. The median age was 61 years (range 32-83) and the median BMI was 26.7 (range 17-36). According to the PTA, 27 patients (54%) underwent simple suture repair while crural mesh buttressing with Phasix-ST® was used in 23 (46%). According to the HSA, the median hiatus area was 4.7 cm² while 26 patients had an HSA greater than 4 cm². The overall concordance rate between PTA and HSA was 94% (47/50). The median hospital stay was 1.9 days (range 1-8) and the 90-day complication rate was 4%. The median follow-up was 18.6 months (range 1-35). Hernia recurrence was diagnosed in 6%. Postoperative dysphagia occurred in one patient (2%). The GERD-HRQL (p < 0.001) and RSI (p = 0.001) were significantly improved.

CONCLUSIONS

The application of PTA for cruroplasty standardization in the setting of HH repair seems effective. While concordance with HSA is high, the PTA seems easier and promptly available in the operative theater with a potential increase in procedure standardization, reproducibility, and teaching.

IMPACT OF BODY MASS INDEX ON PERIOPERATIVE OUTCOMES FOR COMPLEX HIATUS HERNIA BY VIDEOLAPAROSCOPY

BACKGROUND:

The influence of body mass index on perioperative complications of hiatal hernia surgery is controversial in the surgical literature.

AIMS:

The aim of this study was to evaluate the influence of body mass index on perioperative complications and associated risk factors for its occurrence.

METHODS:

Two groups were compared on the basis of body mass index: group A with body mass index <32 kg/m² and group B with body mass index ³32 kg/m². A multivariate analysis was carried out to identify independent predictors for complications. Complications were classified based on the Clavien-Dindo score.

RESULTS:

A total of 49 patients were included in this study, with 30 in group A and 19 in group B. The groups were compared based on factors, such as age, Charlson Comorbidity Index, surgical techniques used, type and location of hiatal hernia, and length of stay. Findings showed that 70% of patients had complex hiatal hernia. In addition, 14 complications also occurred: 7 pleuropulmonary and 7 requiring reoperation. From the seven reoperated, there were three recurrences, two gastrointestinal fistulas, one diaphragmatic hernia, and one incisional hernia. Complications were similar in both the groups, with type IV hiatal hernia being the only independent predictor.

CONCLUSIONS:

Body mass index does not affect perioperative complications in anti-reflux surgery and type IV hiatal hernia is an independent predictor of its occurrence.

Measurement of hiatal surface area and other hiatus oesophageal diameters at computed tomography imaging in patients with gastroesophageal reflux disease and its relationship with hiatal hernia

Background:

The oesophageal hiatus is a long and oblique opening in the diaphragm where the thoracic section of the oesophagus passes into the abdomen. Enlarged hiatal surface and insufficiency are considered to be associated with gastroesophageal reflux disease (GERD) and hiatal hernia (HH). In this study, we aimed to retrospectively evaluate the relationship and the presence of GERD with HH by performing hiatal surface area (HSA) and other hiatal measurements at the thorax and abdominal computed tomography (CT) images in cases without any intra-abdominal or oesophageal surgery history.

Patients and Methods:

A total of 192 patients of GERD+ and 173 cases with GERD− as a control group were included in the study. In CT examinations of 365 patients included in the study, measurements and comments were made by an experienced radiologist in abdominal radiology. In CT scans, the following were evaluated for each case; HSA, hiatus anterior–posterior (A-P) diameter, hiatus transverse diameter, and HH types. The HSA measurement was made with the freehand region of interest in the picture archiving and communication system.

Results:

A total of 365 cases were included in this study; there was a significant difference between the median HSA, A-P diameter, and transverse diameter measurements between GERD− and GERD+ groups (P < 0.001). A statistically significant difference was found between the presence of GERD and HH types (P < 0.001).

Conclusions:

CT imaging helps investigate the presence of HH at GERD+ patients. In addition, pre-operative valuable data can be obtained from the detection of HH types and HSA measurements in cases with HH.

Does composite repair of giant paraoesophageal hernia improve patient outcomes?

BACKGROUND

Paraoesophageal hernia (PEH) is often symptomatic and reduces patients' quality of life (QoL). There is ongoing debate regarding the most effective surgical technique to repair giant PEH. This study aimed to see if an elective laparoscopic non-mesh composite technique of giant PEH repair offered an advantage in symptom control, hernia recurrence, QoL, morbidity and mortality.

METHODS

Data were extracted from a prospectively maintained database of patients undergoing hiatal hernia repair. Composite hernia repairs from inception for giant PEH between March 2009 and December 2015 were included. Perioperative mortality, complications, hernia recurrence rates, prevalence, recurrence of symptoms and QoL were included in analysis.

RESULTS

Inclusion criteria were met by 218 patients. Mean age was 70 (49-93). The average hernia size was 62% (range 30-100%; SD 21). There was one perioperative death and three significant complications (Clavien-Dindo grade III and IV). Recurrence rate was 24.8%. Without recurrence, QoL improved significantly across all domains. Recurrence of hiatus hernia reduced QoL. Surgery resulted in resolution of symptoms other than dysphagia which was incompletely improved. Patients' overall satisfaction with surgery was high.

CONCLUSION

Composite repair of giant PEH is safe with overall good outcomes. Majority of hernia recurrence are small and asymptomatic. Hernia recurrence negatively affected long-term QoL scores.

In vivo measurement of esophageal hiatus surface area using MDCT: description of the methodology and clinical validation

PURPOSE

Accurate estimation of esophageal hiatus surface area (HSA) prior to surgical repair of hiatal hernia is difficult. The ability to do so may assist with following progression of hiatal hernias, choosing the optimal surgical approach and post-surgical evaluation. We developed a method for measurement of HSA using multi-planar reconstruction (MPR) of multi-detector computed tomography (MDCT) scans and sought to validate our method using intra-operative HSA measurements.

METHODS

Patients with thoracic or abdominal CT scans who were scheduled to undergo hiatal hernia repair were identified. A radiologist performed MPR of each MDCT scan to obtain the measured HSA (mHSA). Estimated HSA (eHSA) was obtained using intra-operative measurements of crura length and distance between crural edges. The association between eHSA and the corresponding mHSA was assessed using Pearson correlation. The intra-class correlation coefficient was calculated to assess both intra-observer and inter-observer agreement for the MDCT-MPR technique.

RESULTS

Of 30 subjects included, 16 (53.3%) were female and the median age was 68.5 years. All patients underwent robotic-assisted laparoscopic hiatal hernia repair. The median HSA was 8.1 cm² based on intra-operative measurements and 9.9 cm² based on CT measurements. The correlation coefficient for eHSA and corresponding mHSA was 0.83 (p < 0.001). The intra-class correlation coefficient was 0.97 (p < 0.001) for intra-observer agreement and 0.97 (p < 0.001) for inter-observer agreement.

CONCLUSION

We developed a MDCT-MPR technique that measures HSA in vivo. This technique is reproducible and can be used for pre-operative planning and post-operative follow-up of patients with symptomatic hiatal hernia.

Quantifying tension in tension-free hiatal hernia repair: a new intra-operative technique

BACKGROUND

A similar technique to measure crural closure tension has not been described before and with this method there is now a possibility to optimise this operation with objective measures, a hundred years after it was first described. The aims of this study were to develop a reliable method for measuring the tension of crural closure during hiatal hernia repair and to describe the tension characteristics of crural closure.

METHODS

50 patients underwent crural tension measurement. Hiatal surface area (HSA) was measured intraoperatively and a Sauter FH 50 Universal Digital Force Gauge was used to measure the tension of crural closure during cruroplasty. Outcome measures included the mean tension of the crural closure and the presence of any muscle splitting during the cruroplasty.

RESULTS

A combined total of 148 interrupted cruroplasty sutures were performed in all fifty patients. Each interrupted suture had three tension measurements recorded. The mean standard deviation amongst 148 sets of tension measurements was 0.27. Age, hiatal width and HSA were positively correlated with crural tension with r values of 0.44 (p = 0.0015), 0.81 (p < 0.0001) and 0.78 (p < 0.0001), respectively. Strength of association was low for age (r2 = 0.19) but moderate for hiatal width and HSA (r2 = 0.65 and 0.61, respectively). The presence of muscle splitting occurred at higher crural closure tension (5.3 N vs. 1.62 N, p < 0.0001). The lowest observed mean crural closure tension causing muscle splitting was 3.52 N (IQR 3.93-6.77 N).

CONCLUSIONS

We have developed a technique for measuring the tension of crural closure during laparoscopic repair of hiatal hernia which is reproducible, quick, of low cost and requires only minimal additional equipment. Initial findings suggest that crural closure tension up to ~ 4 N could be the permissible tension threshold for suture cruroplasty and higher tension often results in muscle splitting during cruroplasty.

Mesh reinforcement of paraesophageal hernia repair: Trends and outcomes from a national database

BACKGROUND

Placement of paraesophageal type of "mesh" in paraesophageal hernia repair is controversial. This study examines the trends and outcomes of mesh placement in paraesophageal hernia repair.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried for patients who underwent paraesophageal hernia repair with or without mesh (2010-2017). Demographics, operative approach, and outcomes were compared over time.

RESULTS

Of 25,801, most paraesophageal hernia repair cases were elective (89.3%), without mesh (61.9%), and performed laparoscopically (91.3%).When compared with open paraesophageal hernia repair patients, the patients undergoing laparoscopic paraesophageal hernia repair had lesser rates of reoperation, readmission, mortality, overall complications and major complications (2.7% vs 4.8%, 6.2% vs 9.6%, 0.6% vs 2.9%, 7.1% vs 21.3%, 3.8% vs 11.1%, respectively; all P < .0001). Mesh placement was more common in laparoscopic paraesophageal hernia repair (38.9 vs 29.7, P < .0001) than opern paraesophageal hernia repair. During 2010-2017, mesh placement decreased from 46.2% to 35.2% of laparoscopic paraesophageal hernia repair (P < .0001). Operative times for laparoscopic paraesophageal hernia repair decreased over time, and laparoscpic paraesophageal hernia repair without mesh was consistently less (with mesh: 176.0 ± 71.0 to 149.9 ± 72.5 min, without mesh: 148.6 ± 71.4 to 134.6 ± 70.4). We observed no changes in comorbidities or adverse outcomes over time. Using multivariate analysis to control for potential confounding factors, chronic obstructive pulmonary disease was associated most strongly with adverse outcomes, including mortality (OR 2.53, CI 1.55-4.14), any complications (OR 1.80, CI 1.51-2.16), major complications (OR 1.80, CI 1.51-2.16), readmission (OR 1.63, CI 1.33-1.99) and reoperation (OR 1.49, CI 1.10-2.02). Mesh placement was not associated with adverse outcomes.

CONCLUSION

The placement of mesh during laparoscopic paraesophageal hernia repair is not associated with adverse outcomes. Use of mesh with laparoscopic paraesophageal hernia repair is decreasing with no apparent adverse impact on short-term patient outcomes. Further research is needed to investigate patient factors not captured by this national database, such as characteristics of the hernia, patient symptoms, and hernia recurrence.

Predictors of Hiatal Hernia Recurrence After Laparoscopic Anti-reflux Surgery with Hiatal Hernia Repair: a Prospective Database Analysis

BACKGROUND

The aim of this study is to identify factors that can predict hiatal hernia recurrence (HHR) in patients after anti-reflux surgery with hiatal hernia (HH) repair.

METHODS

A single-institution, prospectively collected database was reviewed (January 2002-October 2015) with inclusion criteria of GERD and laparoscopic anti-reflux (AR) surgery with HH repair. Demographics, esophageal symptom scores, and pre- and post-upper gastrointestinal imaging (UGI) were collected. Mesh usage, HH type (sliding, paraesophageal (HH) or type IV), and size were evaluated, and patients who had HHR versus those who did not (NHHR) were compared. Statistical analysis was performed using IBM SPSS v.23.0.0, with α = 0.05.

RESULTS

Three hundred twenty-two patients met inclusion criteria. Mean age was 56.9 ± 14.8 years (60.9% female), and mean follow-up was 19.9 ± 23.8 months. 88.2% underwent total fundoplication and 11.8% underwent partial fundoplication. HHR rate was 15.5%. HHR patients had larger HH than the NHHR group. There was no significant difference between groups for age, gender, BMI, race, and mesh usage. Only 3 patients (10.3%) with HHR reported mild-to-moderate heartburn, regurgitation, and solid or liquid dysphagia at 12-month follow-up. Overall reoperation rate was 1% in this population.

CONCLUSIONS

HHR is correlated with large hernia size. Mesh use and patient BMI were not predictors, and no correlation was identified between HHR and presence of GERD symptoms. Recurrence after repair is not uncommon, but is asymptomatic in most cases. Reoperation is rare and mesh is not routinely needed. Large asymptomatic HHs in the elderly often do not require intervention.

'Mesh hiatal hernioplasty' versus 'suture cruroplasty' in laparoscopic para-oesophageal hernia surgery; a systematic review and meta-analysis

In laparoscopic 'paraoesophageal hernia' (POH) repair, non-absorbable suture materials have been used to close the crural defects. More recently, various types of prosthetic mesh have been utilized to repair the defect. We conducted a systematic review with meta-analysis of the recent and up to-date studies incorporating 942 POH repairs. We examined the rates of recurrence, reoperation, and complication rates alongside operative time of these two techniques in the management POH. Randomized controlled trials (RCT) and observational studies comparing mesh hiatal hernioplasty versus Suture cruroplasty for Paraoesophageal hernia were selected by searching Medline, Embase, and Cochrane Central database published between January 1995 and December 2016. Predefined inclusion and exclusion criteria were applied to select the studies. The outcome variables analysed are recurrence of hiatal hernia, reoperation, operative time and complications. Nine studies (RCTs = 4 and Observational studies = 5) were analysed totalling 942 patients (Mesh = 517, Suture cruroplasty = 425). The pooled effect size for recurrence favoured mesh repair over suture cruroplasty (OR 0.48, 95% CI 0.32, 0.73, P < 0.05). But the operation time is significantly less in suture cruroplasty (SMD 15.40, 95% CI 7.92, 22.88, P < 0.0001). Comparable effect sizes were noted for both groups which included reoperation (OR 0.35, 95%CI 0.09, 1.31, P = 0.12) and complication rates (OR 1.30, 95%CI 0.74, 2.29, P = 0.36). Our systematic review and meta-analysis demonstrates that mesh hiatoplasty and suture cruroplasty produce comparable results with regards to reoperation rate and complications following the repair of paraoesophageal hernias (POH). Moreover, the study showed significant reduction of recurrence following mesh hiatoplasty.

Mesh implants for hernia repair: an update

INTRODUCTION

Today the use of textile meshes has become a standard for the treatment of abdominal wall hernias and for the reinforcement of any tissue repair as the strength of the implant decreases the recurrence rates. With increasing use, side effects of the textile implants became apparent, as well.

AREAS COVERED

Based on publications in Medline over the past decade, general and specific benefits, as well as risks, are discussed with the challenge to define individual risk-benefit ratios. For meshes, certain high-risk or low-risk conditions can be defined. In an attempt to eliminate mesh-related risks, quality control for medical devices has meanwhile been revised. In both the USA and the EU post-market surveillance studies are required to keep medical devices approved.

EXPERT COMMENTARY

The impact of material on the complication rate will vary depending on the patient's co-morbidity or the risks of the procedure. Even the best material can end up with disappointing results in case of poor healing or poor surgery. On the other hand, when using high-risk devices, most of the complications after excellent surgery with excellent indication can be supposed to be mesh-related. Thus, the use of low-risk devices is recommended even though its advantage may not be demonstrable in clinical studies.

Computer-assisted 3D bowel length measurement for quantitative laparoscopy

BACKGROUND

This study aimed at developing and evaluating a tool for computer-assisted 3D bowel length measurement (BMS) to improve objective measurement in minimally invasive surgery. Standardization and quality of surgery as well as its documentation are currently limited by lack of objective intraoperative measurements. To solve this problem, we developed BMS as a clinical application of Quantitative Laparoscopy (QL).

METHODS

BMS processes images from a conventional 3D laparoscope. Computer vision algorithms are used to measure the distance between laparoscopic instruments along a 3D reconstruction of the bowel surface. Preclinical evaluation was performed in phantom, ex vivo porcine, and in vivo porcine models. A bowel length of 70 cm was measured with BMS and compared to a manually obtained ground truth. Afterwards 70 cm of bowel (ground truth) was measured and compared to BMS.

RESULTS

Ground truth was 66.1 ± 2.7 cm (relative error + 5.8%) in phantom, 65.8 ± 2.5 cm (relative error + 6.4%) in ex vivo, and 67.5 ± 6.6 cm (relative error + 3.7%) in in vivo porcine evaluation when 70 cm was measured with BMS. Using 70 cm of bowel, BMS measured 75.0 ± 2.9 cm (relative error + 7.2%) in phantom and 74.4 ± 2.8 cm (relative error + 6.3%) in ex vivo porcine evaluation. After thorough preclinical evaluation, BMS was successfully used in a patient undergoing laparoscopic Roux-en-Y gastric bypass for morbid obesity.

CONCLUSIONS

QL using BMS was shown to be feasible and was successfully translated from studies on phantom, ex vivo, and in vivo porcine bowel to a clinical feasibility study.

Functional Results after Repair of Large Hiatal Hernia by Use of a Biologic Mesh

BACKGROUND

The aim of this observational study is to analyze the results of patients with large hiatal hernia and upside-down stomach after surgical closure with a biological mesh (Permacol(®), Covidien, Neustadt an der Donau, Germany). Biological mesh is used to prevent long-term detrimental effects of artificial meshes and to reduce recurrence rates.

METHODS

A total of 13 patients with a large hiatal hernia and endothoracic stomach, who underwent surgery between 2010 and 2014, were included. Interviews and upper endoscopy were conducted to determine recurrences, lifestyle restrictions, and current complaints.

RESULTS

After a mean follow-up of 26 ± 18 months (range: 3-58 months), 10 patients (3 men, mean age 73 ± 13, range: 26-81 years) were evaluated. A small recurrent axial hernia was found in one patient postoperatively. Dysphagia was the most common complaint (four cases); while in one case, the problem was solved after endoscopic dilatation. In three cases, bloat and postprandial pain were documented. In one case, an explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis, pyloroplasty was performed without success. The data are compared to the available literature. It was found that dysphagia and recurrence rates are unrelated both in biological and in synthetic meshes if the esophagus is encircled. In series preserving the esophagus at least partially uncoated, recurrences after the use of biological meshes relieve dysphagia. After the application of synthetic meshes, dysphagia is aggravated by recurrences.

CONCLUSION

Recurrence is rare after encircling hiatal hernia repair with the biological mesh Permacol(®). Dysphagia, gas bloat, and intra-abdominal pain are frequent complaints. Despite the small number of patients, it can be concluded that a biological mesh may be an alternative to synthetic meshes to reduce recurrences at least for up to 2 years. Our study demonstrates that local fibrosis and thickening of the mesh can affect the outcome being associated with abdominal discomfort despite a successful repair. The review of the literature indicates comparable results after 2 years with both biologic and synthetic meshes embracing the esophagus. At the same point in time, reconstruction with synthetic and biologic materials differs when the esophagus is not or only partially encircled in the repair. This is important since encircling artificial meshes can erode the esophagus after 5-10 years.

A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair

BACKGROUND

Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair.

DATA SOURCE

Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis.

CONCLUSIONS

The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

Surgery for Type III-IV hiatal hernia: anatomical recurrence and global results after elective treatment of short oesophagus with open and minimally invasive surgery

OBJECTIVES

Type III-IV hiatal hernia (HH) is associated with a true short oesophagus in more than 50% of cases; dedicated treatment of this condition might be appropriate to reduce the recurrence rate after surgery. A case series of patients receiving surgery for Type III-IV hernia was examined for short oesophagus, and the results were analysed.

METHODS

From 1980 to 1994, 60 patients underwent an open surgical approach, and the position of the oesophago-gastric junction was visually localized; from 1995 to 2013, 48 patients underwent a minimally invasive approach, and the oesophago-gastric junction was objectively localized using a laparoscopic-endoscopic method. The patients underwent a timed clinical-instrumental follow-up that included symptoms assessment, barium swallow and endoscopy. The results were considered to be excellent in the absence of symptoms and oesophagitis; good, if symptoms occurred two to four times a month in the absence of oesophagitis; fair, if symptoms occurred two to four times a week in the presence of hyperaemia, oedema and/or microscopic oesophagitis; and poor, if symptoms occurred on a daily basis in the presence of any grade of endoscopic oesophagitis, HH of any size or type, or the need for antireflux medical therapy. The follow-up time was calculated from the time of surgery to the last complete follow-up.

RESULTS

Among the open surgery patients, 78% underwent abdominal fundoplication, 10% the Belsey Mark IV procedure, 8% laparotomic Collis-Nissen fundoplication and 3% the Pearson operation. Among the minimally invasive surgery patients, 44% underwent a laparoscopic floppy Nissen procedure and 56% a left thoracoscopic Collis-laparoscopic Nissen procedure. The postoperative mortality and complication rates were 1.6% (1/60) and 15% for open surgery and 4.1% (2/48) and 12.5% for minimally invasive surgery. A total of 105 patients were followed up for a median period of 96 months. Five relapses occurred after open surgery (5/59, 8%) and two after minimally invasive surgery (2/46, 4%). Among the 105 patients, excellent, good, fair and poor outcomes were observed in 38%, 44%, 9% and 9%, respectively.

CONCLUSIONS

These data suggested that the selective treatment of short oesophagus in association with a Type III-IV hernia reduced the anatomical recurrence rate and achieved satisfactory outcomes.

CLINICALTRIALSGOV ID

NCT01606449.

Multiplanar MDCT measurement of esophageal hiatus surface area: association with hiatal hernia and GERD

BACKGROUND

Accurate measurement of esophageal hiatus size is clinically important, especially when antireflux surgery is planned. We present a novel method for in vivo measurement of esophageal hiatal surface area using MDCT multiplanar reconstruction. We aimed to determine whether large hiatal area is associated with hiatal hernia and gastroesophageal reflux disease.

METHODS

We retrospectively analyzed subjects prospectively enrolled in the COPDGene(®) project. We created two test groups, one with hiatal hernia on chest CT and one with GERD on medical treatment identified by history without hernia. Matched control groups were formed. We performed CT postprocessing to define the double-oblique plane of the esophageal hiatus, on which the hiatal surface area is manually traced.

RESULTS

Subjects with hernia (n = 48) had larger mean hiatus areas than matched controls (6.9 vs. 2.5 cm(2), p < 0.0001), and were more likely to have GERD (42 vs. 10 %, p < 0.0005). Subjects with mixed (type III) hernias had larger hiatuses compared to subjects with sliding (type I) hernias, who, in turn, had larger hiatuses than subjects without hernia (p < 0.0001). Hernia-negative subjects with GERD (n = 55) did not have significantly larger mean hiatal areas compared to matched controls (3.0 vs. 2.5 cm(2), p = 0.12). Twenty measurements obtained by two radiologists showed correlation of 0.93, with mean difference of 0.5 cm(2) (p = 0.20).

CONCLUSIONS

We devised a method to measure in vivo esophageal hiatal surface area using MDCT reconstruction and established the normal size range for the first time. This methodology has the potential to guide decision-making in antireflux surgery technique preoperatively, and assess surgical result postoperatively. The presence of hernia correlated with large hiatuses and GERD. However, hiatal area failed to identify those with GERD in the absence of hiatal hernia.