Paraesophageal Hernia Repair Followed by Cardiac Tamponade Caused by ProTacks

Collateral damage of wandering ProTacks

CASE

A 75-year-old man presented with mixed obstructive and storage lower urinary tract symptoms (LUTS). He had undergone transurethral resection of the prostate (TURP) 5 years and laparoscopic inguinal hernia repair 20 years ago. He had a stone adherent to the bladder wall and an occlusive prostate.

OUTCOME

He underwent a re-do TURP and stone removal. Stone removal revealed an underlying metal coil straddling the bladder wall, which had served as a nidus for stone formation. The metal ring was a ProTack staple from previous hernia surgery, which had detached and wandered into the bladder. At follow-up after 12 weeks, the patient was asymptomatic, and his urine was sterile. Therefore, he chose to be treated conservatively for the ProTack and was started on periodic follow-up and cystoscopic surveillance. Shortly after review, he developed intestinal obstruction, which resolved spontaneously and was thought to be secondary to adhesions from other tacks that had migrated into the peritoneal cavity.

CONCLUSION

We have reported a case of a ProTack from a previous hernia repair migrating into the bladder and also causing intestinal obstruction. The case is very rare because of the combination of complications. Clinicians should beware of delayed complications and damage to other organs due to metallic hernia staples.

Cardiac tamponade after robotic hiatal hernia repair from liver sling stitch: Case report of a rare complication and literature review

Introduction and importance

Cardiac tamponade following hiatal hernia repair is a rare and potentially fatal complication most often associated with the use of mechanical fixation devices for hiatal mesh reinforcement. Only three cases have been reported with sutures alone, and none following robotic hiatal surgery.

Case presentation

A 54-year-old patient underwent elective robotic hiatal hernia repair with Toupet fundoplication during which a sling suture was placed to elevate the left lateral segment of liver. No mesh or mechanical fixation devices were used. Eight hours postoperatively, the patient developed hemodynamic instability. Cardiac tamponade was diagnosed on bedside echocardiogram and the patient underwent emergent pericardiocentesis with subsequent stabilization. The remainder of the postoperative course was notable for pericarditis which was treated with aspirin and colchicine.

Clinical discussion

While the use of suture-based liver retraction has the advantages of avoiding an additional port and potential collision between retractor holder and robot arms, it constitutes a novel risk factor for cardiac tamponade. Prompt diagnosis via bedside echocardiography is essential and may facilitate percutaneous rather than operative management.

Conclusion

Suture-based liver retraction in minimally invasive foregut surgery should be used judiciously until further data is available. Surgeons should maintain a high index of suspicion for tamponade in the setting of postoperative hypotension after its use.

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Hypotension may be a sign of cardiac tamponade after robotic hiatal hernia repair.

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Slings or other suture techniques that abut the diaphragm may cause tamponade.

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Prompt diagnosis and drainage can prevent life-threatening hemodynamic compromise.

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Multidisciplinary care is essential to manage recurrent effusion or pericarditis.

Laparoscopic Surgery for Recurrent Hiatal Hernia

Surgical treatment of hiatal hernia (HH) is well standardized. However, recurrence is observed in 15%-60% of cases, and is challenging to manage. The aim of this study was to analyze the causes of surgical failure and provide some guidelines for treatment. The symptoms of recurrent HH vary widely, and include persistent reflux, dysphagia, and permanent discomfort, leading to a marked change in the quality of life. Morphological and functional pretherapeutic evaluation is necessary to determine whether the symptoms are due to recurrent HH, and to understand the cause of failure. Redo surgery is technically difficult and challenging, and should only be used in symptomatic patients whose symptoms are definitively those of recurrent HH.

Iatrogenic cardiac tamponade as a mortal complication of peri-hiatal surgery. Analysis of 30 published cases

Iatrogenic cardiac tamponade (ICT) is a dreadful complication of peri-hiatal surgery and vast majority occur during a hernia repair. Strikingly, against all warnings, the incidents and related deaths seem to be increasing. The aim of this review is to provide insight on how to prevent and challenge ICT. PubMed search identified 30 distinct ICTs with 10 deaths (33.3%) due to peri-hiatal procedures. Twenty-nine operations were mechanical repairs and laparoscopic anti-reflux surgery was the primary cause (n:18). Graft fixation (n:23) and helical tacks (n:13) were the main offenders. Initial symptom was hypotension affecting 92%. Seven ICTs were only identified at autopsy. All treated patients except one underwent a drainage. Almost all ICTs were caused by injury to the diaphragmatic dome, anterior to hiatus. In conclusion, peri-hiatal surgery-related ICT is extremely fatal. ICT mainly occurs during the repair of a hernia, a benign condition and therefore must be prevented. Graft fixation, around the ante-hiatal diaphragmatic dome must be abandoned. If mesh-augmentation is absolutely necessary, meticulous stitching must be preferred instead of fixators. Persistent hypotension during or following a peri-hiatal operation is an alarming sign of ICT. Increased awareness is mandatory for prevention and survival.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

Cardiac Tamponade as a Life-Threatening Complication of Laparoscopic Antireflux Surgery: The Real Incidence and 3D Anatomy of a Heart Injury by Helical Tacks

Background: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury.

Materials and Methods: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was “posterior” or “posterior + anterior.” Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive.

Results: One CT occurred in 1302 consecutive LARS (0.076%). The incidence is 0% when “no” (379) or “posterior” (880) graft is used as opposed to 2.3% rate in “posterior + anterior” (43) grafting. The distribution of “offensive,” “nonoffensive but nearest,” and “safe” tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone.

Conclusion: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

A word of caution: never use tacks for mesh fixation to the diaphragm!

Background

The mesh fixation technique used in repair of hiatal hernias and subxiphoid ventral and incisional hernias must meet strenuous requirements. In the literature, there are reports of life-threatening complications with cardiac tamponade and a high mortality rate on using tacks. The continuing practice of tack deployment for mesh fixation to the diaphragm and esophageal hiatus should be critically reviewed.

Methods

In a systematic search of the available literature in May 2017, 23 cases of severe penetrating cardiac complications were identified. The authors became aware of two other cases in which they acted as medical experts. Furthermore, the instructions for use issued by the manufacturers of the tacks were reviewed with regard to their deployment in the diaphragm.

Results

Twenty-three of 25 cases (92%) with severe cardiac injuries and subsequent cardiac tamponade were triggered by the use of tacks in the diaphragm. In six cases (24%), these related to ventral and incisional hernias with extension to the subxiphoid area, and in 19 cases (76%) to mesh-augmented hiatoplasty. Twelve of 25 (48%) patients died as a result of pericardial and/or heart muscle injury with cardiac tamponade despite heart surgery intervention. In the tack manufacturers’ instructions for use, their deployment in the diaphragm, in particular in the vicinity of the heart, is contraindicated. Likewise, the existing guidelines urgently advise against the use of tacks in the diaphragm, recommending instead alternative fixation techniques.

Conclusions

Tacks should not be used for mesh fixation in the diaphragm above the costal arch.

Cardiac complications after laparoscopic large hiatal hernia repair. Is it related with staple fixation of the mesh? -Report of three cases

Introduction

Laparoscopic Nissen operation with mesh reinforcement remains being the most popular operation for large hiatal hernia repair. Complications related to mesh placement have been widely described. Cardiac complications are rare, but have a fatal outcome if they are misdiagnosed.

Presentation of cases

We sought to outline our institutional experience of three patients who developed cardiac complications following a laparoscopic Nissen operation for large hiatal hernia repair.

Discussion

Laparoscopic hiatoplasty and Nissen fundoplication are safe and effective procedures for the hiatal hernia repair, but they are not exempt from complications. Fixation technique and material used must be taken into account. We have conducted a review of the literature on complications related to these procedures.

Conclusion

In the differential diagnosis of hemodynamic instability after laparoscopic hiatal hernia repair, cardiac tamponade and other cardiac complications should be considered.

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Three cases with different clinical expression of cardiac tamponade after laparoscopic large hiatal hernia repair.

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We review cardiac complications related to laparoscopic hiatal hernia repair.

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It is necessary to consider the risk of injury to the surrounding tissues during the anchorage of the mesh to the diaphragm.

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Cardiac complications must be considered in the postoperative period of mesh hiatoplasty.

Reinforcement of hiatal defect repair with absorbable mesh fixed with non-permanent devices

AIM

To report the results of an open label prospective study on a new technique for laparoscopic hiatal hernia (HH) repair with absorbable mesh fixed with absorbable materials Methods: From January 2011 to May 2013, 43 patients were treated; group A, 20 patients submitted to laparoscopic sleeve gastrectomy (LSG); group B, 13 patients submitted to revisional surgery for the diagnosis of HH and symptomatic GERD post-LSG; and group C, ten patients submitted to 360° fundoplication. All patients underwent cruroplasty reinforced with bio-absorbable mesh fixed with absorbable tacks and/or fibrin glue. Conversion rate, intra-operative complications, operative time (tacks vs tacks plus fibrin glue), perioperative complications, perioperative symptoms and radiological control set the criteria for clinical/surgical evaluation.

RESULTS

Conversion and mortality rate was 0%. The mean time for mesh fixation with the tacks vs tacks plus fibrin glue was 6.2 ± 2 vs 7.3 ± 3 min. The remission of GERD symptoms was observed in 39 patients, and we did not observe any cases of mesh-related complications at a mean follow-up of 17.4 months. Recurrence rate was 2.3% (one asymptomatic patient of group B).

CONCLUSIONS

Reinforcement with absorbable mesh-cancel bio mesh is a safe and effective option for laparoscopic HH repair in normal weight and obese patients.