Laparoscopic Repair of Paraesophageal Hernias with Falciform Ligament Buttress

Raymond Laird, DO, Nathan Richards, MD, Fred Brody, MD, MBA, FACS. The George Washington University Medical Center.

Introduction: Multiple techniques have been used to decrease recurrence rates following a paraesophageal hernia repair including buttressing the crura with synthetic and biological mesh. However, synthetic mesh is associated with erosions and dysphagia while biologic buttresses are expensive and have not shown long-term decreases in recurrence rates. This study documents clinical outcomes and recurrence rates following laparoscopic paraesophageal hernia repairs using the falciform ligament as a crural buttress.

Methods: All patients undergoing a laparoscopic paraesophageal hernia repair from January 1, 2012 to June 30, 2013 were included in the analysis. A prospective database was created to record demographics, medications, and radiologic studies. All patients underwent an endoscopic gastroduodenoscope with either an upper gastrointestinal (GI) series or a computed tomogram (CT). Esophageal manometry and pH monitoring were selectively performed. Inclusion criteria required a hiatal defect greater than 5cm. Patients with recurrent hiatal hernias or prior gastric surgery were excluded. Operatively, all patients underwent a laparoscopic hiatal hernia repair with a Toupet fundoplication and a falciform ligament buttress. A total symptom score using a standard questionnaire to assess 9 symptoms was assessed for all patients pre- and postoperatively at 6 months. Symptoms were evaluated in terms of severity and frequency. An upper GI (UGI) series was obtained at 6 months. A paired t-test with a confidence interval of 95% was used with a p<0.05 as significant.

Results: 21 patients underwent laparoscopic paraesophageal hernia repair with a falciform buttress. Mean age was 65 ± 5.4 with 18 females. All procedures were completed laparoscopically with no intraoperative complications. There was no mortality and 1 patient had a seizure postoperatively. At 6 months postoperatively, the mean symptom severity score decreased from 16.7 to 3.17, the mean symptom frequency score decreased from 16.8 to 3.67, and the mean total symptom score decreased from 33.5 to 6.83. All decreases were significant at a p<0.05. All patients remain off H2 blockers or PPIs and there were no recurrences on UGI.

Conclusions: Early data suggests that a 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 costs 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 for paraesophageal hernias.

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