Mesh crural reinforcement of giant hiatal hernia with laparoscopic approach: results in 100 consecutive patients

Emanuele L. G. Asti, MD, FACS, Andrea Lovece, MD, Luigi Bonavina, MD, FACS. IRCCS Policlinico San Donato

Background: Laparoscopic repair of large hiatal hernia is associated with high recurrence rate. In the past few years several studies analyzed the potential utility of both synthetic non-absorbable and biologic absorbable meshes to reinforce the hiatus. The first type could potentially decrease the recurrence rate, but it may also cause dysphagia and visceral erosion; the efficacy of the second type is still debated.

Objectives: To evaluate the objective and subjective outcomes of 100 consecutive patients undergoing laparoscopic repair of large hiatal hernia with synthetic resorbable mesh augmentation. The primary outcome was anatomical recurrence rate as measured by endoscopy and barium swallow study. Secondary outcomes were safety and long-term quality of life.

Methods: Single center, observational cohort study. One-hundred consecutive patients with a hiatal hernia who underwent laparoscopic repair with mesh augmentation were included. All patients underwent laparoscopic repair with a partial fundoplication and a posterior cruroplasty reinforced with a pre-shaped biosynthetic mesh with a “U” configuration (Gore Bio A® tissue reinforcement, Flagstaff, AZ). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. All patients had a minimum follow-up of 6 months. Upper gastrointestinal endoscopy and barium swallow were routinely performed between 6 and 12 months postoperatively and repeated over time every 1-2 years or as needed.

Results: From September 2011 to December 2015, a total of 100 patients were included in the study All surgical procedures were completed laparoscopically. The median follow-up was 30+12 months. No mesh-related complications occurred throughout the follow-up. Nine patients (9%) had a recurrent hernia ≥2cm measured by endoscopy. Median post-operative GERD-HRQL scores was 2, compared with 14 pre-operatively (p<0,001). Recurrence free probability at 12 and 58 months was respectively 0.99 (CI 0.97 – 1.00) and 0.84 (CI 0.74 – 0.97).

Conclusions: The use of a synthetic, absorbable mesh to reinforce the hiatus is a safe procedure and seems to be effective and durable over time. Further randomized studies are needed to confirm this observation.