Selective Use of Mesh in Laparoscopic Paraesophageal Hernia Repair: an Attractive Option

E. Auger-Dufour, MD, L.E. Ferri, MD PhD, L.S. Feldman, MD, M.C. Vassiliou, MD, P. Kaneva, G.M. Fried, MD. Steinberg-Bernstein Center for Minimally Invasive Surgery & Innovation, McGill University, Montreal, Canada.

INTRODUCTION: Use of mesh in laparoscopic paraesophageal hernia repair has been associated with an improved short-term recurrence rate in randomized control trials. However, numerous case reports of mesh-related complications can be found in the literature, creating some reluctance to routine mesh use. The objective of this study is to determine our short-term recurrence rate with selective use of mesh.

METHODS: We reviewed a prospective database of patients undergoing a laparoscopic paraesophageal hernia repair between 1997 and 2009 in our center. Mesh was placed selectively when anatomical factors that might increase the risk of recurrence were present (tension on the crural repair, peritoneal stripping, attenuated crural muscles). UGI series were done routinely 3-6 months postoperatively to evaluate for recurrence. Patient characteristics, mesh use and recurrence rate were evaluated.

RESULTS: Laparoscopic repair of a primary paraesophageal hernia was performed in 104 consecutive patients (mean age 69 years; mean BMI 27). The female to male ratio was 2 to 1. The mean operative time was 140 minutes. Primary crural repair was done in 80% of patients (83/104); mesh repair in 20% (21/104) (3 PTFE, 18 Surgisis). The median length of stay was 2 days (1- 142). Radiologic follow-up was achieved at a mean of 6.4 months in 92% of patients. The overall recurrence rate is 13.5%(14/104). 4 recurrences occurred in the first 15 cases. After this learning curve, the recurrence rate was 11.2% (10/89). The recurrence rates were 14% (3/21) in the mesh group and 13% (11/83) in the primary repair group. 57% (8/14) of recurrences are sliding or migration of the wrap in the chest; 43% (6/14) are true paraesophageal recurrences.

CONCLUSION: Considering the potential risks associated with mesh placed at the hiatus, we feel a selective approach is attractive. We were able to achieve an acceptable short-term anatomic recurrence rate while avoiding the use of mesh in 80% of our patients.