Laparoscopic management of large hiatus hernia with mesh cruroplasty

A Narrative Review on Treatment of Giant Hiatal Hernia

Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.

Laparoscopic repair of giant hiatal hernia for elderly patients

Background

Giant hiatal hernias are more common in older patients and can significantly reduce their quality of life. However, open surgery for patients of advanced age is thought to be associated with high morbidity and mortality. The aim of this retrospective study was to evaluate the safety of laparoscopic giant hiatal hernia repair for elderly patients as compared to younger patients.

Methods

From January 2015 to January 2020, 152 consecutive patients underwent laparoscopic mesh repair of giant hiatal hernia. Two cases of missing follow up were excluded. Patients were divided into an elderly group (N=62, age ≥75) and a younger group (N=88, age <75). Interrupted non-absorbable suture was applied for crus closure and as an additional reinforcement, the mesh was fixed with absorbable tacks or medical glue. Procedure-related complications, score-based variation tendency of symptoms, gastrointestinal quality of life index (GIQLI), mortality, recurrence rate, hemoglobin, and the use of PPI were investigated.

Results

All patients underwent the procedure uneventfully. Dor fundoplication was used in 39 patients (62.9%) in the elderly group and 44 (50.0%) in the younger group and no case was converted to open. While the elderly group had a significantly higher percentage of ASA Class level 3 and cardiovascular and cerebrovascular diseases as compared to the younger group, the two groups had similar operative times, intraoperative blood loss, and percentage of intrathoracic stomach. Elderly group patients tended to have higher perioperative complications including pneumonia (3.2%) and atelectasis (3.2%) without statistical significance, as well as transfer to the intensive care unit compared, to younger patients (9.7% vs. 3.2%; P=0.144). The mean post-operative hospital stay was also significantly shorter in the younger group (2.8 days) compared with the elderly group (3.5 days; P=0.001). There was no mortality, recurrence, mesh-related complications such as visceral erosion, adhesion, or severe dysphagia during follow up in the two groups, and both groups demonstrated significant improvement in GIQLI scores and hemoglobin. The percentage of patients who needed PPI was also reduced in both groups.

Conclusions

Laparoscopic mesh repair of giant hiatal hernia for elderly patients is safe and effective when performed at experienced centers.

Reparación laparoscópica de hernia hiatal gigante

Introducción. La reparación laparoscópica es el estándar de tratamiento en hernia hiatal gigante. Sin embargo, a pesar de su baja morbilidad, la tasa de recurrencia sigue siendo alta. Nuestro objetivo fue describir los resultados de la reparación laparoscópica de hernia hiatal gigante, independientemente de la técnica de cruroplastia empleada. Métodos. Se llevó a cabo un estudio retrospectivo de pacientes llevados a reparación laparoscópica de hernia hiatal gigante en el periodo 2009-2017. Se analizaron los datos demográficos, la técnica quirúrgica, las complicaciones y la estancia hospitalaria. Se revisaron los resultados de la endoscopia, la radiografía de vías digestivas altas y la escala de síntomas GERD-HRQOL, obtenidos luego de un año de cirugía. Resultados. Se incluyeron 44 pacientes con un tamaño promedio de la hernia de 7 cm. Se practicó cruroplastia con sutura simple en 36,4 %, sutura más refuerzo con politetrafluoroetileno (PTFE) o dacrón, en 59,1 %, y se usó malla en 4,5 %. Hubo 12 complicaciones, la estancia hospitalaria promedio fue de 3,5 días y no hubo mortalidad. Se encontró recurrencia endoscópica o radiológica en 6/20 pacientes, todas pequeñas y asintomáticas. En 23 pacientes, la escala GERD-HRQOL reportó un valor promedio de 7,7 y 78 % de satisfacción. Solo un paciente requirió cirugía de revisión. Conclusión. El método preferido de reparación laparoscópica de la hernia hiatal gigante es la cruroplastia sin malla, técnica asociada a baja morbilidad y adecuado control de los síntomas. La tasa de recurrencia es similar a la reportada en la literatura. Se requieren estudios prospectivos con seguimiento completo a largo plazo para validar estos resultados.

The use of autologous fascia lata graft in the laparoscopic reinforcement of large hiatal defect: initial observations of the surgical technique

Background

Even though there is no consensus, many authors believe that in the cases of large hiatal defects, structurally altered crura and/or absence of peritoneal lining, a crural reinforcement should be performed. Reinforcement could be performed with different techniques and different type of mesh, either synthetic or biologic. The disadvantages of mesh repair include the possibility of serious complications and increased costs especially in the usage of composite or biologic mesh.

Methods

The study includes 10 cases of reinforced primary suture line of the pillars with autologous fascia lata, in elective laparoscopic repair of the giant PEH with a large hiatal defect and friable crura. After intraopreative confirmation of the large hiatal defect (hiatal surface area of more than 8 cm²) and friable crura, an autologous fascia lata graft was harvested in the usual manner and placed in on-lay fashion to reinforce the pillar suture line. We analyzed surgical technique, complications, and initial follow-up of the patients.

Results

Average hiatal surface area (HSA) in our series was 10.6 cm² (range 8.1 to 14.4 cm²). The average duration of operation was 203.9 min/3.4 hours (range 160–250 min). Except for a mild hematoma in the harvesting region that resolved spontaneously, there were no procedure related complications and 30 days mortality rate was zero. The average postoperative length of stay was 6.5 days (5–8 days). Out of 10 patients, 5 completed the annual follow-up visit, while 8 completed a 6- month follow-up visit. So far there is no hernia recurrence and/or problems with swallowing function. However, one patient has felt a mild discomfort in the harvested region that does not influence normal daily activities.

Conclusions

Autologous fascia lata graft hiatal reinforcement represents a technically feasible, easy, and available option for the on-lay reinforcement of large hiatal defects with friable crura in the laparoscopic repair of giant PEHs.

Current readings: Failed hiatal hernia repair

Recurrent hiatal hernia is noted in up to 70% of patients undergoing reoperative antireflux procedure. Role of short esophagus vis-à-vis a need for Collis gastroplasty, mesh reinforcement of hiatus, and access of surgery (thoracotomy vs laparotomy) have been debated. The aim of this article is to review selected recent publications that address these issues.

Initial Outcomes of Laparoscopic Paraesophageal Hiatal Hernia Repair with Mesh

The use of mesh in laparoscopic paraesophageal hiatal hernia repair (LHR) may reduce the risk of late hernia recurrence. The aim of this study was to evaluate initial outcomes and recurrence rate of 92 patients who underwent LHR reinforced with a synthetic bioabsorbable mesh. Surgical approaches included LHR and Nissen fundoplication (n = 64), LHR without fundoplication (n = 10), reoperative LHR (n = 9), LHR with a bariatric operation (n = 6), and emergent LHR (n = 3). The mean length of hospital stay was 2 ± 3 days (range, 1 to 30 days). There were no conversions to open laparotomy and no intraoperative complications. One of 92 patients (1.1%) required intensive care unit stay. The 90-day mortality was zero. Minor complications occurred in 3.3 per cent, major complications in 2.2 per cent, and late complications in 5.5 per cent of patients. There were no perforations or early hernia recurrence. The 30-day reoperation rate was 1.1 per cent. For patients with available 1-year follow-up, the overall recurrence rate was 18.5 per cent with a mean follow-up of 30 months (range, 12 to 51 months). LHR repair with mesh is associated with low perioperative morbidity and no mortality. The use of bioabsorbable mesh appears to be safe with no early hiatal hernia recurrence or late mesh erosion. Longer follow-up is needed to determine the long-term rate of hernia recurrence associated with LHR with mesh.