Use of Biologic Keyhole Mesh in Large Paraesophageal Hernias: A Safe Technique With Low Rates of Dysphagia

Jeffrey R Watkins, MD, Houssam G Osman, MD, Ernest L Dunn, MD, Michael S Truitt, MD, Rohan Jeyarajah, MD. Methodist Dallas Medical Center

Introduction – The purpose of our study is to identify the incidence of dysphagia in a series of patients who underwent laparoscopic paraesophageal hernia repair (LPEHR) with placement of keyhole biologic mesh. Improved outcomes have been shown with LPEHR over open techniques but there is still much debate as to the placement of mesh. Biologic mesh has shown great promise, but only the U-shaped onlay has been extensively studied. A paucity of data exists on the application of biologic mesh in a keyhole configuration, however, despite the potential for improved outcomes. Post-operative dysphagia has historically been a concern of this procedure and subsequently slowed the adoption of keyhole mesh. The advent of a new generation of biologic mesh has renewed interest in application of keyhole mesh.

Methods and Procedures – We reviewed 30 consecutive patients over a two-year period who underwent LPEHR with primary suture cruroplasty, Dor fundoplication, gastrostomy tube placement and human acellular dermal matrix keyhole mesh reinforcement. All procedures were performed by a single surgeon. Patient charts were reviewed and any complaints of post-operative reflux or dysphagia were noted. Any post-operative hernia on imaging was defined as radiographic recurrence.

Results – Of the thirty consecutive patients who underwent LPEHR, three patients (10%) had preoperative dysphagia that was mild. All three of these patients had unchanged dysphagia after LPEHR with keyhole mesh. Return of mild reflux symptoms occurred in 6 (20%) patients, of which only two had radiographic recurrence demonstrated as a a small amount of stomach about the hiatus. Repeat imaging was performed in 11 (37%) patients at a mean follow-up of 8 months with two demonstrating radiographic recurrence. All hernias were classified as large type 3 hiatal hernias on pre-operative imaging. Overall mean follow-up was 7 months (2-27 months). Average age was 64 (31-83) while average BMI was 30 (23-39). There were no post-operative complications and no patients required re-operation.

Conclusions – Laparoscopic paraesophageal hernia repair with biologic keyhole mesh reinforcement has low recurrence rates with minimal post-operative dysphagia. The traditional belief that keyhole mesh has a higher incidence of dysphagia is not a concern with the new generation of biologic mesh. We advocate using keyhole mesh in patients with large paraesophageal hernia.

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