Tension-Free Anatomical Reconstruction of Complex Hiatal Hernia Using Porcine Dermal Collagen

D Oweis, MBBS MRCSEd, D Veeramootoo, MBBS MRCS MD, NJ Smart, MBBSHons PhD MRCSEd, SA Wajed, MA BMBCh MChir FRCS. Department of Upper Gastro-Intestinal Surgery, Royal Devon and Exeter NHS Foundation trust, Exeter, United Kingdom.

Introduction:
The management of complex para-oesophageal hernias has been the subject of much debate. Direct symptoms such as dysphagia, regurgitation, shortness of breath, result from the anatomical defect. The use of mesh in Hiatus Hernia (HH) repair is controversial; it has its complications such as erosions and dysphagia based on mesh type, but may reduce recurrence. The aim of this study is to evaluate the role of porcine dermal collagen (Permacol^TM Biologic Implant) in a tension free repair.

Methods and Procedures:
Between October 2004 and June 2010, 25 patients underwent a planned laparoscopic repair of complex Hiatus Hernia with Permacol^TM mesh. All patients had a pre-operative work-up including; upper gastro-intestinal endoscopy, contrast imaging (Barium Swallow); and a CT-Scan if indicated. The procedure consisted of: hernia sac dissection, reduction and excision, oesophageal mobilisation and lengthening, gastroplasty/ gastropexy as required and an anti–reflux procedure when indicated. A tension free hiatal reconstruction with onlay Permacol^TM was then fashioned.

Results:
Twenty five patients (male: female = 10:15) with a median age of 75 years (range 29-90) were included. The median BMI was 27 (range=20-33) and ASA grade was 2. Presenting symptoms were: significant reflux (18), regurgitation (15), dysphagia (13), odynophagia (5), vomiting (11), chest pain (2), abdominal pain (16), and shortness of breath (5). Six patients had previous HH repair and 4 required urgent surgery. Seven patients had incarcerated hernias and 7 had gastric volvulus. Gastroplasty was required in 4 patients and anti-reflux procedure was added in 14 cases. Mesh size was commonly 5x5cm (2×3 in 1 and 10×10 in 2). Conversion to open surgery was required in 1 case and controlled pleural breach occurred in 5. Median operating time was 5.25 hours (range 4 – 6.25). Median length of stay was 4 days (range=2-29). Mortality was nil and post-operative problems were: 1 early recurrence, necessitating re-operation, from non-compliance with dietary advice; 1 mediastinal leak managed conservatively. At routine follow-up all patients had symptomatic relief with no recurrence.

Conclusion:
Tension-free repair of complex hiatal hernias with Permacol^TM is safe and feasible with no specific complications or early recurrence.