Oscar M Crespin, MD, Robert B Yates, MD, Ana V Martin, MD, Carlos A Pellegrini, MD, Brant K Oelschlager, MD. University of Washington
Background
Operations of complex hiatal hernias, paraesophageal hernias (PEHs) or large recurrent hiatal hernias, have a better chance of success when a tension-free closure of the hiatus can be done. Because in many of these patients the closure involves tension or inability to close, reinforcement with mesh has been recommended. A relaxing incision in the diaphragmatic crus may help accomplish a tension free closure. This study evaluates the use of crural relaxing incisions and biologic mesh reinforcement of the hiatus in patients undergoing laparoscopic repair of such hernias.
Methods
Between 2007 and 2013, we repaired 230 primary and 138 recurrent hiatal hernias. A minimum of 6 months of radiologic and clinical follow-up was available for 146 (40%) patients, including 16 with relaxing incisions. Radiologic recurrence was defined as any intrabdominal content above the diaphragm, detected by an experienced radiologist. Postoperatively, symptoms were classified as a) No recurrence: when patients reported improvement or complete resolution of symptoms; and b) Recurrence: when patients reported little or no improvement in symptoms compared to pre-op, the development of a new symptom, or the need for medical, endoscopic or surgical treatment.
Results
Relaxing incisions were performed on 29 (7.9%) patients (14 primary and 15 recurrent hiatal hernias). All were buttressed with biologic mesh. The incision was placed on the right (n=22), left (n=3), or bilaterally (n=4). The Table summarizes radiologic and symptomatic recurrence as well as reoperation rates, in those patients with radiographic and clinical follow-up. Two of four reoperations were for symptomatic diaphragmatic hernias that developed through left relaxing incisions. No diaphragmatic hernias occurred in patients with right relaxing incisions. There were no complications associated with use of biologic mesh at the hiatus; mortality was zero.
TensionFree (n=36) | Tension+Mesh (n=94) | RelaxingIncision + Mesh (n = 16) | Right Relaxing Incision (n = 12) | Left RelaxingIncision (n = 3) | Bilateral RelaxingIncision (n = 1) | |
Radiologic Recurrence | 21 (58%) | 36(38%) | 9 (56%) | 6 (50%) | 2 (67%) | 1(100%) |
Symptomatic Recurrence | 6 (17%) | 3 (3%) | 3 (19%) | 0 (0%) | 2 (67%) | 1(100%) |
| Reoperation | 1 (3%) | 1 (1%) | 2 (13%) | 0 (0%) | 2 (67%) | 0 (0%) |
Conclusions
Relaxing incisions of the right crus decrease the tension of hiatal closure, and may allow closure of large defects. The addition of a biologic mesh over the incision and the hiatus itself appears to be safe when hiatal tension is present (no morbidity or mortality) with similar recurrence rate to tension free repairs in the short term. By contrast, left crural relaxing incisions resulted in a high recurrence rate, sometimes through the incision itself. Larger long-term studies should be performed to determine the role this strategy may play in the repair of PEH.