Long-Term Outcomes Following Laparoscopic Repair of Large Hiatus Hernias Performed by Trainees Versus Consultant Surgeons

BACKGROUND

The laparoscopic approach is the preferred method for repair of large hiatus hernias but can be technically challenging. Training surgeons need experience as the primary operator to gain competency in this operation. However, learning the procedure should not compromise the functional long-term outcome for patients. The aim of this study was to determine whether any difference in long-term outcomes exists for patients having a laparoscopic large hiatus hernia repair performed by a trainee versus a consultant surgeon.

METHODS

A total of 648 suitable patients who had undergone laparoscopic repair of a large hiatus hernia were identified from a prospective database. Cases were divided into two groups based on whether the primary operator was a trainee or a consultant surgeon. Demographics, perioperative data, revisions and patient-reported clinical outcomes via standardised questionnaires were compared.

RESULTS

There were no statistically significant differences in the clinical outcomes for patients undergoing laparoscopic repair of a large hiatus hernia performed by a trainee versus a consultant surgeon, with comparable patient-reported outcomes for heartburn, dysphagia, and overall satisfaction with the outcome following surgery. Median operative time was approximately 20 min longer for trainees (p = <0.0001). Revisional surgery rates were similar for the two groups.

CONCLUSIONS

Patients operated on by trainees have equivalent long-term clinical outcomes to patients operated on by consultant surgeons. For these patients, surgery can be safely performed by supervised trainees.

Impact of Laparoscopic Repair of Large Hiatus Hernia on Quality of Life: Observational Cohort Study

BACKGROUND

Laparoscopic surgery has proven safe and effective in the treatment of large hiatus hernia. Differences may exist between objectively assessed surgical outcomes, symptomatic scores, and patient-reported outcomes.

METHODS

An observational, single-arm cohort study was conducted in patients undergoing primary laparoscopic repair with crura mesh augmentation and Toupet fundoplication for large (> 50% of intrathoracic stomach) type III-IV hiatus hernia. Data were extracted from hospital charts and a prospectively updated research database. The main study outcome was quality of life assessed by the Gastroesophageal reflux disease Health-Related Quality of Life (GERD-HRQL) score and the Short-form 36 (SF-36).

RESULTS

Between 2013 and 2016, 37 out of 49 operated patients completed the comprehensive quality-of-life evaluation at the 2-year follow-up. The GERD-HRQL score significantly decreased compared to baseline (p < 0.001). All items of the SF-36 significantly improved compared to baseline (p < 0.05). Both Physical and Mental Component Summary scores were significantly higher than preoperative scores, with a medium Cohen's effect size (-0.77 and 0.56, respectively). At the 2-year follow-up, symptoms had disappeared in the majority of patients. The use of proton-pump inhibitors significantly decreased compared to baseline (13.5 vs. 86.4%, p < 0.001). Also, the use of antidepressants and benzodiazepines significantly decreased after surgery (8.1 vs. 32.4%, p < 0.001). The overall alimentary satisfaction score was > 8 in 92% of patients. There were no safety issues related to the use of the absorbable synthetic mesh. The incidence of anatomical hernia recurrence was 5.4%, but no patient with recurrent hernia required surgical revision.

CONCLUSIONS

Laparoscopic repair of large hiatus hernia with mesh and partial fundoplication is associated with symptomatic relief, no side-effects, and a significant improvement in disease-specific and generic quality of life at 2-year follow-up.

Laparoscopic management of large hiatus hernia with mesh cruroplasty

PURPOSE

Laparoscopy has become the standard surgical approach to surgery for gastrooesophageal reflux disease (GERD) and hiatal hernia repair with excellent long-term results and high patient satisfaction. However several studies have shown that hiatal hernia repair, especially large hiatus are associated with high recurrence rate. Mesh reinforcement has been proposed for repair of large hiatus hernia. The objective of this study was to evaluate the role of mesh cruroplasty in management of large hiatus hernia (> 5 cm).

METHODS

Between February 2002 to December 2007, 73 patients (28 men and 45 women) who underwent laparoscopic hiatal hernia repair with mesh cruroplasty were included in our study. Mesh reinforcement (cruroplasty) was used for repair of large hiatus hernia (>5 cms hernial defect). Mean age was 50.4 years (range 30-72 years). Follow up included barium swallow of patients at 3 months and yearly thereafter.

RESULTS

Seventy-three patients underwent mesh cruroplasty for large hiatus hernia. We were able to adequately mobilise the oesophagus to achieve an intra-abdominal length of at least 3 cm in all patients. Intraoperative complication rate was 8.21% (6/73), intraoperative complications included pleural tear, bleeding from splenic capsule laceration and short gastric vessels. Postoperative complication rate was 4.1% (3/73), which included complete dyspahgia, atelactasis and pneumonia. Mean duration of hospitalisation was 3.5 days (range 3-9 days). Five patients (5/73) were lost to follow up. Four patients (5.8%) developed recurrence on routine follow up. No mesh related complications were noted on long-term follow up period. Mean follow up period was 3.2 years (range 5 months-6 years).

CONCLUSION

Our data supports the use of mesh in hiatal hernia repair, especially in large hiatus hernia as it leads to low recurrence rates. Longer follow up and more randomised controlled trials are needed to establish laparoscopic mesh cruroplasty as standard technique for large hiatal hernia repair.