Laparoscopic Paraesophageal Hernia Repair With Falciform Ligament Buttress

Jeffrey N Harr, MD, MPH, Fred Brody, MD, MBA. The George Washington University

Introduction:

Laparoscopic paraesophageal hernia repairs have been performed since the early 1990’s with a wide range of methods and recurrence rates. Multiple techniques are used to decrease recurrence rates, including buttressing the repair with synthetic and biological mesh. However, synthetic mesh is associated with erosions and dysphagia, and biologic buttresses are expensive and have not shown long-term decreases in recurrence rates. Therefore, a laparoscopic repair using the falciform ligament as a buttress may improve outcomes with minimizing complications.

Methods:

A prospective database was established for patients undergoing a laparoscopic paraesophageal hernia repair. Baseline demographics, operative details, and preoperative symptom questionnaires were obtained. The questionnaire evaluated vomiting, nausea, early satiety, bloating, postprandial fullness, epigastric pain, epigastric burning, chest pain, chest burning, and dysphagia. Each symptom was scored in terms of severity and frequency. All laparoscopic paraesophageal hernias were repaired in a similar fashion using a standard 5-port foregut technique. The hiatal hernia was reduced, and the sac was mobilized and excised. The crura were then reapproximated with interrupted sutures. The falciform ligament was divided with extension to the liver edge. The flap was rotated under the left lateral segment, and splayed over the crural repair. The flap was then secured to the crura, and a fundoplication was performed. Postoperatively, all patients underwent an upper gastrointestinal series at six months and a symptom questionnaire was completed. Pre- and postoperative symptom scores were compared using a t-test with significance of p<0.05.

Results:

To date, 41 patients have undergone a laparoscopic paraesophageal hernia repair with a falciform ligament buttress. The mean age was 61.4 years, and 61% were female. Six-month follow-up is available for 27 patients. There were no conversions to laparotomy. There have been 3 (7.5%) radiologic recurrences, but only 1 patient became symptomatic requiring reoperation. Presently, all patients remain off H2 blockers or PPI’s. All symptom categories were significantly improved in both severity and frequency except for early satiety. In addition, total symptom scores were significantly decreased at 6 months (Table 1).

Table 1

Category

Mean ± SEM

(Pre-Op)

Mean ± SEM

(Post-Op)

p-value

Total Symptoms Severity

12.04±2.04

3.27±1.03

< 0.0001

Total Symptoms Frequency

12.41±2.03

3.46±1.03

< 0.0001

Total Symptoms Score

24.44±4.06

6.48±2.03

< 0.0001

Conclusion:

Early data suggests that laparoscopic paraesophageal hernia repair using the falciform ligament as a buttress is a viable option to repair large hiatal hernias. The falciform ligament is readily available in most patients, and avoids the cost of a biological mesh, and the possible complications of synthetic mesh. Long-term follow-up is required to verify the utility of this approach to decrease recurrence rates of paraesophageal hernia repairs.

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