Unidirectional barbed sutures as a novel technique for laparoscopic hiatal hernia repair

Federico Perez Quirante, MD, Lisandro Montorfano, MD, Nisha Dhanabalsamy, MD, Rajmohan Rammohan, MD, Alex Ordonez, MD, Abraham Abdemur, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS. Cleveland Clinic Florida

Introduction: There is much debate surrounding the method of closure during hiatal hernia repairs (HHR). Although some evidence exists on the advantage of the use of mesh to reinforce the hiatal repair, concerns persist on the safety of a foreign body in this location.  This study aims to describe the initial results of a novel surgical technique for primary hiatal defect closure during HHR using unidirectional barbed suture.

Materials and methods: Between 2010 and 2015, patients who underwent laparoscopic hiatal hernia repair were retrospectively reviewed. Patients were assessed with office visits with detailed follow up. Those who presented with dysphagia after surgery underwent further studies. Student’s T test and Chi-Square Test of Independence were used to asses the statistical significance of our findings.

Results: 362 patients underwent laparoscopic HHR. In 295 patients the hiatal closure was performed using unidirectional non-absorbable barbed suture alone, while in 67 patients the hiatal closure was obtained with non-absorbable barbed suture and reinforced with mesh. Operative time was 87.1±40.3 min (mean ± SD) in the non-absorbable barbed suture group vs. 91.3± 30.64 min in the non-absorbable barbed suture plus mesh group (p=0,453). The average overall follow-up was 8.39±11.9 months.

For all procedures, 12% of the operated patients were originally asymptomatic whereas the rest presented with at least one of the following symptoms: 29% dysphagia, 14% heartburn, 25% regurgitation, 7% night cough, 12% nausea/vomiting, 2% anemia, 40% gerd, 9% chest pain, 2% hoarseness, 4% burping, 1% hiccups, 5% incarcerated hernia, 5% achalasia, 10% upper GI bleeding.

Twenty-six patients out of 354 (97.7%) visited the hospital for follow-up within 6 months after surgery. The non-absorbable barbed suture group compared to the non-absorbable barbed suture plus mesh group presented the following symptoms: dysphagia, 29 (9.8%) vs.  4 (6.0%) p=0.321, persistent GERD 6 (2.1%) vs. 3 (4,5%) p=0.246 , regurgitation  27 (9.1%) vs. 6 (9.0%) p=0.959 and pseudoachalasia  3 (1.0%) vs. 1 (1.5%) (p=0.736). No clinical hernia recurrence was noted in either group.

Conclusions: The adoption of continuous unidirectional barbed suture provides a safe, efficient, and effective alternative to traditional hiatal closure techniques. Our findings warrant further studies to establish the long-term efficacy of using barbed suture during laparoscopic HHR.