Laparoscopic repair of large type II and III hiatal hernia: potential utility of crural reinforcement with a synthetic absorbable mesh

Emanuele L.G. Asti, Andrea Lovece, Andrea Sironi, Luigi Bonavina. IRCCS Policlinico San Donato

Background: Laparoscopic repair of large mixed and paraesophageal hiatal hernia, which represent up to 15% of all hiatal hernias, is associated with high recurrence rate. The use of mesh to reinforce the hiatus can decrease the recurrence rates but may cause severe complications, such as postoperative dysphagia and visceral erosion. We designed a case control study to test this hypothesis.

Objectives: The primary end points of the study were safety and efficacy of a synthetic, absorbable mesh for hiatus repair in the laparoscopic treatment of large (≥5cm) type II and III hiatal hernia.

Methods: From October 2009 to September 2014, 80 patients were included in the study. Forty patients (Group A) underwent crura repair, reinforcement with polyglycolic acid trimethylene carbonate mesh (Bio A, Gore®) and fundoplication; 40 patients (Group B) underwent simple crura repair and fundoplication. We investigated pre and postoperative symptoms using the GERD-HRQL questionnaire. Barium swallow study and upper endoscopy were performed at 6 months post-operatively and then yearly to detect recurrences and mesh related complications.

Results: All the operations were completed laparoscopically. After a mean follow-up of 36 months (IQ range: 18-54), no mesh-related complications occurred. The incidence of persistent grade II dysphagia was 3% in each group (p=NS). Reflux symptoms requiring anti-secretory drugs accounted for 5% of patients in group A, and 12,5% for group B (p=0,1). Recurrent hiatal hernia (≥ 2cm) was detected in 3 patients (10%) in the group A and in 8 patients (27%) in the group B (p=0,080). Only 3 patients in group B were symptomatic.

Conclusions: Laparoscopic repair of large hiatal hernia using an absorbable synthetic mesh is safe and effective and may reduce the anatomical recurrence rate.

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