Bernard Dallemagne, MD, Silvana Perretta, MD, Jacques Marescaux, MD. IRCAD, Department of Digestive and Endocrine Surgery, University of Strasbourg, France.
Introduction: although surgical repair of symptomatic hiatal hernia is well standardized, controversy still exists regarding the crural repair. Several studies have reported high rates of anatomical recurrence after primary suture repair, due to inevitable tension consequently, many authors recommend a reinforced repair. The indication for mesh use, the type of mesh to use, and the closure technique are controversial. Furthermore prosthetic hiatal reconstruction may lower recurrence but presents a known rate of complications. This video demonstrates the use of an innovative technique of crural approximation using a non reasorbale, self-tensioning reinforced plegeted suture, the Cruralink TM (Cousin Biotech).
Methods and Procedures: here we show the use of this tension free crural closure technique in a 56-year-old man with a 10 years’ history of typical GERD symptoms. The preoperative workup included endoscopy, esophageal manometry and ph-impedence studies confirming the diagnosis of GERD, which was associated with Barrett’s esophagus. Upper gastrointestinal series (UGI) showed a moderate size hiatal hernia. The cruralink TM system comprises of a curved needle with and attached 2/0 non resorbable suture with two 2 cm preloaded PET-silicone non-woven pledgets, and an integrated adaptable cinching mechanism which allows the surgeon to adjust the tension of the closure according to the size of the crural defect and the characteristics of the crus. While the surgery was carried out according to our standard approach the crural defect was closed using one CruralinkTM device which granted a solid yet gentle crural approximation. A floppy Nissen fundoplication was then created.
Results: the UGI series on post-operative day 1 and at 12 months confirmed the patency of the GEJ and the absence of recurrence. Laparoscopic crural repair with the Cruralink TM system proved to be technically feasible and clinically effective over a 12 months objective follow-up period.
Conclusions: the cruralink TM crural closure device could be a faster alternative solution to prosthetic mesh repair for large hiatal defect closure unsuitable for simple cruroplasty.