Ragui W Sadek, MD, FACS, Andrew M Wassef, BS. Rutgers Robert Wood Johnson Medical School
Background
Controversy exists among surgeons whether wrapping and buttressing of the diaphragm reduce rate the of recurrence of paraesophageal/hiatal hernia (HH), in comparison to simple primary repair of the diaphragm. From 2010 to 2013, 87 laparoscopic hiatal hernia repairs (HHR) were performed, 26 with wrapping and buttressing, and 61 just with primary repair of the diaphragm. We propose primary repair of the diaphragm is sufficient to reduce rate of recurrence to levels rivaling paraesophageal hernia repairs performed with wrapping and buttressing techniques.
Methods
All patients who have received a HHR from January of 2010 to December of 2013 were examined. Patients were then separated into groups depending on the technique performed for HHR. Group A (n=61) consisted of patients who received primary diaphragmatic repair of HH. Group B (n=26) consisted of patients who receive HHR with buttressing and wrapping techniques. Patients were assessed for current clinical symptoms, general quality of life following surgery 1-4 years postoperatively (QOL) and determined the possibility of a recurrence if symptoms of HH still persisted following HHR by a gastrointestinal series (UGI). HH recurrence was marked by the greatest measured vertical height of stomach being 2 cm or more above the diaphragm.
Results
There was a median follow-up of 41 months (range 7 to 59 months). In Group A 4 patients were diagnosed with recurrent HH (RHH) (6.6%), while Group B 8 patients were diagnosed with RHH (30.1%). There was no statistically significant difference (p=0.04) in relevant symptoms or QOL between patients undergoing primary repair and buttressed/wrapping repair of HH. There were no strictures, dysphagia, or other complications related to the use of buttressing or wrapping techniques.
Conclusions
There does not appear to be a higher rate of complications or side effects following PR or wrapping/buttressing repair of HH. PR of HH can have a lower comparative rate of recurrence when compared to buttressing and wrapping techniques. It is important to note that PR of HH using a standard laparoscopic technique will not retrieve such results. A new technique for PR of HH was utilized involving the dissection of the ventral and dorsal diaphragmatic hiatus with suture closures at opposing ends of the diaphragm.