The Influence of Hiatal Hernia Size On Recurrence Rate Following Laparoscopic Hiatal Hernia Repair

Aaron M Williams, BA, Salomon Levy, MD, Daniel L Davenport, PhD, Margaret Plymale, MSN, RN, J. Scott Roth, MD. The University of Kentucky, Department of Surgery, Division of Gastrointestinal Surgery and Minimally Invasive Surgery.

INTRODUCTION: The cranio-caudal height of a hiatal hernia has been demonstrated to be associated with the rate of recurrence following laparoscopic repair without the utilization of mesh. The adjunct of mesh utilized to reinforce the hiatal closure at the time of hiatal hernia has not clearly impacted long-term hernia recurrence rates in long-term studies. This study aims to evaluate the impact of hiatal hernia size upon recurrence rate amongst laparoscopic repairs utilizing a mesh reinforcement.

METHODS AND PROCEDURES: An IRB approved retrospective review of all cases of hiatal hernia repair from 2005 to 2012 at a single center was performed. Patient demographics, comorbid conditions, preoperative evaluation, operative details and postoperative outcomes were measured. Hiatal hernia size was classified as either small or large based upon preoperative endoscopy or barium swallow. Small hiatal hernias were defined as less than 6cm in cranio-caudal height or 50% intrathoracic stomach, while a large hiatal hernia was defined greater than or equal to 6cm in height or 50% intrathoracic stomach. Radiologic recurrence was defined by radiologic herniation greater than 2 cm, while clinical recurrence was defined as radiologic recurrence with recurrent symptoms associated with the hiatal hernia.

RESULTS: 154 patients underwent hiatal hernia repair. 75 patients (48.7%) were identified with preoperative and postoperative imaging with a mean follow up of 8.4 months. Radiographic recurrences were seen in 10.6% of patients, of which half of these patients (5.3%) were experiencing symptoms. Amongst the study group, 33 (44%) patients had a small hiatal hernia, while 42 (56%) patients had a large hiatal hernia. Recurrences following large and small hiatal hernia repairs occurred similarly (14.3% vs. 6.1%, p=0.45, respectively). Among mesh-reinforced repairs, postoperative recurrence rates were similar between large and small hiatal hernias (14.7 vs. 5.9%, p=0.65). Similarly, non-mesh repairs demonstrated no difference in recurrence rates among large hiatal hernias when compared to small hiatal hernias (12.5% vs 5.9%, p=1.0).

CONCLUSIONS: Laparoscopic hiatal hernia repair is associated with a relatively low short-term recurrence rate with or without the adjunct of mesh. Clinical recurrences occur less commonly than radiographic recurrences. Cranio-caudal extent of a hiatal hernia as measured by preoperative endoscopy or barium studies does not directly impact hernia recurrence rate. Recurrence rates are similar between mesh and non-mesh repairs for both small and large hernias. Appropriate indications for mesh use at the time of hiatal hernia repair are unclear. Future studies should address variables beyond the cranio-caudal extent of the hernia.

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