Laparoscopic Paraesophageal Hiatal Hernia Repair with Bio-A Mesh. Short-term Results.

Agustin Duro, MD, Demetrio Cavadas, MD, PhD, Axel F Beskow, MD, Fernando G Wright, MD, Santiago Lenzi, MD, Juan R Medici, MD, Pablo J Castellaro, MD. Hospital Italiano de Buenos Aires

BACKGROUND: The use of mesh during hiatal hernia repair is controversial. Different types of prosthesis have been proposed in order to reduce anatomic recurrence but none has yet proven any benefit. The aim of this study was to evaluate the short-term outcomes of hiatal hernia repair with the use of a synthetic absorbable mesh in terms of recurrence rate, morbidity and mortality.

METHODS: We retrospectively analyzed 42 patients who had crural reinforcement during paraesophageal hiatal hernia repair with a polyglycolic acid trimethylene carbonate bioabsorbable mesh (GORE® BIO-A®). All patients were treated by laparoscopy, with a four-trocar technique and a Nathanson liver retractor. Transhiatal esophageal dissection was undertaken until at least 3 cm of intra-abdominal esophagus was achieved without tension. Posterior cruroplasty was done using interrupted 0 silk suture and reinforced with a U-shaped mesh onlay. Hiatus closure was always calibrated with a 58 French bougie. The procedure ended with a Nissen fundoplication. Barium esophagram was systematically performed at 1, 6 and 12 months postoperatively or when new onset of symptoms occurred. Recurrence was defined as any protrusion of the wrap above the diaphragm.

RESULTS: There were 29 women and 13 men with a mean age of 61.5 years (35-82). No complications related to the mesh appeared. The overall morbidity was 11.9%. One patient with CREST syndrome who had a preoperative esophageal stricture and a manometry with aperistalsis presented with acute dysphagia caused by food bolus impaction and required endoscopic dilatation. Other complications include: pulmonary embolism (2), atrial fibrillation (1) and pleural effusion (1). There was no postoperative mortality. Mean follow-up was 15.5 months (6-32). Sixty-nine percent of patients had more than one year of follow up. There were three recurrences (7.14%) with a mean time to diagnosis of 17,3 months (12-24).

CONCLUSION: The use of this synthetic bioabsorbable mesh for the treatment of large paraesophageal hiatal hernias is safe and may reduce recurrence rate in the short-term. Further follow-up is needed to evaluate long-term results.