Interwoven Technique for hiatal crural repair with synthetic and bioresorbable mesh using barbed suture.

Peter M Denk, MD, FACS, Rachel Dearie. GI Surgical Specialists

Minimally invasive hiatal hernia repair has evolved with increasing surgeon expertise with the goal of more durable repair while minimizing potential complications. Contemporary synthetic mesh repair of all types of abdominal hernia had lead to better understanding of the role of larger mesh pore size in tissue incorporation providing more strength with less risk of infection through extensive tissue ingrowth. Synthetic mesh use in hiatal crural repair however brings risk of gastric and esophageal erosion. Bioresorbable mesh varieties probably mitigate this erosion risk at the expense of weaker crural repair.

We present a novel technique of hiatal crural repair that balances synthetic and bioresorbable mesh benefits with a mechanically sound and technically facile interwoven suturing method with barbed suture. Strict adherence to meticulous primary crural closure is maintained. Large pore synthetic mesh completely effaced to the crura will provide high strength and minimize risk of infection. Bioresorbable mesh effacement to the synthetic mesh both protects the stomach and esophagus from the synthetic mesh and assures broad attachment of the bioresorbable mesh to the crura which is problematic with other mesh fixation techniques.

Barbed suture provides continuous fixation at each of the interweaves through the crural fascia and mesh, firmly effacing the mesh layers together more effectively and expeditiously than individual sutures.

We present video demonstrating the Interwoven Technique in a patient with a moderate sized crural defect. Short term (up to one year) follow up in 5 patients using this technique shows no mesh related complications, no hernia recurrence, and operative times comparable to alternative mesh fixation strategies. Ongoing follow up with attention to radiologic recurrence and synthetic mesh complications will determine the potential long-term value of this method for crural repair.

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