Introduction: The use of mesh to potentiate the hiatal closure during laparoscopic foregut surgery is increasing among surgeons, as some consider this the standard of care. Our objective is to evaluate the incidence of mesh removal during revisional foregut surgery and to examine the complications that can arise from the use of mesh near the esophageal hiatus. Our objective is to compare indications for surgery and perioperative outcomes between those patients with and without prior mesh hiatoplasty.
Methods and Procedures: Our design is an IRB-approved retrospective cohort study from a single tertiary-care referral center. Between December 2006 and September 2009, sixty-nine (69) patients underwent revisional foregut surgery at the esophageal hiatus. Patients undergoing planned operations for obesity or achalasia were excluded from analysis. Of these sixty-nine (69) patients, ten (10) had previous hiatal mesh (PHM).
Results: The patients in each group were similar with regard to age (range 17-76 yrs), BMI (range 17.7-48.1), and ASA (median 3). PHM and NM patients had similar rates (70% and 68%, respectively) and types of anatomic failure (misplaced, slipped, herniated and/or twisted fundoplication). There was no statistically significant difference in outcomes between PHM and NM patients with regard to estimated blood loss (430 cc vs. 105 cc, p=0.09), operative time (4.19 hrs vs. 2.74 hrs, p=0.07), blood transfusion (1.1 units vs. 0.2 units, p=0.29), or length of stay (6.2 days vs. 3.2 days, p=0.16). Of the ten PHM patients, four required a major resection with anastomosis, whereas only four of 59 required such a resection in the NM group. Therefore, the relative risk of requiring a major resection is 5.9 times as high in PHM patients as compared to NM patients (95% CI = 1.754, 19.84; p=0.01). The rate of major resection was similar between those patients with biological and permanent mesh.
Conclusions: Our study demonstrates that the presence of mesh at the esophageal hiatus is associated with an increased risk of requiring a major resection during a revisional procedure. The pattern of failure was not different in patients with hiatal mesh, suggesting that the use of mesh at initial repair does not eliminate the potential need for revisional operation. Thus, when performing an initial hiatal hernia repair, the risk of increased hiatal hernia recurrence if not using mesh should be weighed against the potential risk of a subsequent major resection if using mesh.
Session: Podium Presentation
Program Number: S045