Functional Results of Lower Esophageal Sphincter Mechanism Following Different Techniques Used for Cruroraphy for Laparoscopic Hiatal Hernia Repair ; Early Results of Randomized Controlled Trial

Aim:
The prospective randomized trial was designed to evaluate the impact of different cruroraphy techniques used for laparoscopic repair of hiatal hernias.

Material and Methods:
Between January 2010-december 2011 , patients were randomly assigned for 3 groups having hiatal hernia> 2 cm. 24 h pH monitoring was performed using pHday2 Menfis,Italy and esophageal manometry was performed using 8 lumen catheter,Dynosmart,Menfis,Italy.The original audit population of 27 patients referred to our Gastrointestinal Motility Laboratory of Surgery. Patients were referred to laboratory for typical or atypical symptoms to represent hiatal hernia and GERD. All endoscopic evaluations were also performed by the same surgical team. Each group has 9 patients with DeMeester score> 18, low LES pressure and normal esophageal motility. All patients had laparoscopic floppy Nissen fundoplication as a standard procedures, but different cruroraphy techniques. First group had figure of 8 suturing, second group had tension free mesh repair and third group had figure of 8 suturing plus mesh cruroraphy. All patients had endoscopic and manometric evaluation of the esophagus at the first post-operative month.
Results:
Post-operative esophageal manometric evaluation revealed LES pressure increase as group 3>group 1>group 2. Sticking sensation of the particles which were eaten following the post operative period was less in group 2< group 1<group 3.Gas bloating syndrome was less in group 1> group 2> group 3.
Conclusion:
The anatomic components of the anti-reflux barrier include the crural fibers of diaphragmatic esophageal hiatus, the smooth muscle sling fibers of the gastric cardia and the semicircular and clasp fibers of the distal esophagus. Tension free mesh cruroraphy is an easy and quick method of cruroraphy technique, and had induced small amount of gas bloating syndrome with a moderate increase in LES pressure. Our results are not statistically reliable because of the inadequate number of the cases. The study will be continued and future results set light to hiatal hernia repair .