Laparoscopic Lightweight Mesh Repair vs Primary Repair With Teflon Patch Buttress for Large and Giant Hiatal Hernias: Prospective Randomized Trial

V.v. Grubnik, Prof, A.v. Malynovskyy, PhD, O.v. Grubnik, PhD, V.v. Ilyashenko, PhD. Odessa national medical university

Background. Mesh repair of large and giant hiatal hernias may reduce recurrence rate compared to primary repair. However, it may cause prosthesis-related esophageal strictures and erosions. It was suggested that primary posterior suture repair with buttressing by teflon patches may substitute mesh repair and decrease or completely exclude esophageal strictures.
Design of study. Prospective randomized study was conducted to compare these two methods of laparoscopic repair. There were 36 patients in lightweight mesh arm (I), and 36 patients in teflon patch arm (II), operated from 2007 to 2009. Time frame – 20 months. Inclusion criteria: type I, II and III hiatal hernias, including complicated by GERD; diameter of hernia defect measuring 8 to 12 cm. Exclusion criteria: unable to undergo laparoscopic hiatal hernia repair due to severe comorbidities (ASA III and more), previous major surgery with severe adhesions; age < 20 years and > 80 years; BMI < 16 and > 39 kg/m2; oesophageal motility disorders, peptic strictures, shortening; history of oesophageal/gastric/duodenal surgery; relapsing course of ulcer disease.
Methods. The lightweight mesh repair was performed using original technique (“sandwich” technique): the mesh was fixed to the crura posteriorly to the esophagus, and then crura were sutured to each other covering the mesh and thus preventing the contact of esophagus with the mesh. Primary outcome measures were: rates of anatomical and functional recurrences of hiatal hernia and GERD; rates of repair-related dysphagia/oesophageal stricture/prosthetic erosion. Recurrence of hiatal hernia, i.e. anatomical recurrence, were assessed by symptom questionnaire with visual analogue scales, mainly by barium study. Recurrence of GERD, i.e. functional recurrence, will be evaluated by symptom questionnaire with visual analogue scales, endoscopic examination, and 24 hour pH-testing. Short- and long-term dysphagia, including due to repair-related oesophageal stricture, will be assessed by symptom questionnaire with visual analogue scales, barium study, and endoscopic examination. Secondary outcome measures were: quality of life and satisfaction assessed by GERD-HRQL score, operative time, morbidity, and postoperative hospital stay.
Results. Two arms were statistically comparable by demographic and preoperative data. 1 patient from lightweight mesh arm (I) and 2 patients from teflon patch arm (II) lost from follow-up. There were 2 anatomical and functional recurrences in I arm (5,7 %), and 4 patients in II arm (11,7 %) (p < 0,05). There were no cases of repair-related dysphagia/oesophageal stricture/prosthetic erosion in both arms.
Conclusion. Although there were no differences between arms in terms of repair-related esophageal complications, laparoscopic lightweight mesh repair of large and giant hiatal hernias using original “sandwich” technique results in better long-term outcome compared to primary repair with teflon patch buttressing in terms of anatomical and functional recurrence rate.