Learning curve for laparoscopic repair of very large hiatal hernia

Background  

Laparoscopic repair of a large hiatal hernia is technically challenging. A significant learning curve likely exists that has not been studied to date.     

Laparoscopic repair of large paraesophageal hiatal hernia

BACKGROUND: The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. METHODS: Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. RESULTS: Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). CONCLUSIONS: Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.     

Composite mesh repair of a large paraesophageal hiatal hernia

We describe the first experience in Italy with a new pre-cut composite polytetrafluoroethylene (PTFE)/expanded PTFE (ePTFE) prosthesis designed for the hiatal region. A 78-year-old female patient with a large paraesophageal hiatal hernia with migration of the left transverse colon inside the hiatal defect (type IV hernia) received laparoscopic repair by means of the composite V-shaped mesh. The procedure was completed laparoscopically and a partial fundoplication was performed. A favorable outcome was assessed by barium swallow radiograms performed on postoperative day 7. A complete resolution of the symptoms was noted at follow-up 1 month postoperatively. This report confirms the feasibility, effectiveness, and added advantages of the composite V-shaped mesh in tension-free repair of a large hiatal hernia.     

免补片法腹腔镜腹股沟疝修补术

目的 探讨免补片法腹腔镜下腹股沟疝修补的有效性.方法 回顾分析广东省第二人民医院2001年1月至2004年3月,应用腹腔镜免补片法治疗92例腹股沟疝的手术后恢复情况及随访结果,并与同期91例腹腔镜完全腹膜外疝修补手术(totally extraperitoneal laparoscopichemioplasty,TEP)的结果相比较.结果 免补片组与TEP组手术时间分别为(21±4)min与(70±16)min(t=28.01,P<0.05)、住院天数分别为(3.5±1.0)d与(4.8±1.2)d(t=7.96,P<0.05)、下床活动时间分别为(1.0±0.5)d与(1.8±0.7)d(t=8.90,P<0.05)、术后疼痛持续时间分别为(1.0±0.5)d与(2.5±0.7)d(t=16.69,P<0.05)、住院总费用分别为(4500±500)元与(8000±820)元(t=34.89,P<0.05),免补片组均明显优于TEP组,差异有统计学意义.免补片组无皮下血肿及阴囊水肿发生,TEP组皮下血肿8例(8.7%)(χ~2=6.48,P<0.05).免补片组与TEP组术后48h C-反应蛋白(CRP)分别为(3.9±0.3)mg/dl与(8.8±0.5)mg/dl(t=80.48,P<0.05).所有病例随访(56.9±6.2)个月,免补片组复发率为0,TEP组复发率为2.1%(χ~2=0.51,P>0.05).结论 腹腔镜免补片治疗腹股沟疝安全、可行,恢复快、住院时间短、费用少.     

腹腔镜食管裂孔疝修补术的临床分析

目的：总结腹腔镜下应用补片行食管裂孔疝修补和部分胃底折叠术治疗食管裂孔疝的初步经验。方法：2007年5月至2009年12月为13例食管裂孔疝患者行腹腔镜食管裂孔疝修补术或（和）胃底折叠术。观察术后相关并发症。结果：13例手术均获成功,无中转开放手术。手术时间130-205min,平均152min,术中基本无出血。术后第2天开始饮水,第3天开始进流质饮食。术后住院4-6d。1例直接缝合者术日晚发生气胸,经胸腔穿刺抽气消失。1例胃底折叠术患者在开始进普通饮食时有轻微吞咽困难,术后1个月临床症状消失。术后随访6-12个月,平均8.5个月,行钡餐造影或CT检查均未见复发。结论：腹腔镜下应用补片和（或）胃底折叠术治疗食管裂孔疝安全有效,值得临床推广。     

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BACKGROUND: Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus. METHODS: A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected. RESULTS: The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure. CONCLUSIONS: Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.     

Tension-free repair of hiatal hernia during laparoscopic fundoplication: a ten-year experience

Background: The breakdown of a hiatal hernia repair can lead to clinical failure. The use of prosthetic material at the esophageal hiatus to strengthen the crural repair is relatively new and questions remain. This report examines the safety and efficacy of a tension-free crural repair with mesh.Patients and methods: Since 1993, 135 consecutive patients (19–86) [9 re-do] completed laparoscopic tension-free hiatal hernia repair prior to Nissen wrap. Esophageal hiatus was patched with a PTFE mesh (first 112 patients) or a PTFE/ePTFE composite (23 patients) secured across the defect with staples to each crura. 130 patients completed a phone questionnaire during 2003/2004 (mean f/u 64 months).Results: There have been no short-term nor long-term infections related to the PTFE mesh. Symptoms were resolved or improved and resolved with meds in 122/130 (94%). Early re-herniation occurred in one patient after vigorous exercise.Conclusions: Mesh repair/patch of the esophageal hiatus can be done without infection, with results similar to standard crural repair and consistent with surgical principles of non-tension.     

Characteristics of laparoscopic and open hernia repair simulation models: a systematic review

Hernia - Barriers to education in open and laparoscopic hernia repair technique include a steep learning curve and reduced theatre time for junior surgical trainees. This is particularly evident...     

腹腔镜下造口旁疝修补术

目的 探讨腹腔镜下应用补片行造口旁疝修补术的方法、安全性及临床效果.方法 2004年11月至2006年4月对6例造口旁疝进行腹腔镜补片疝修补术.结果 6例均在腹腔镜下行腹腔粘连松解和补片固定,顺利完成造口旁疝修补手术.手术时间65～130 min,平均90 min .术后住院6～9 d,平均7 d.术后疼痛达3个月以上者有2例;浆液肿2,经穿刺抽液和加压包扎后治愈.无手术死亡,无造口感染和肠瘘发生.随访7～26个月,平均13个月,未见造口旁疝复发.结论 腹腔镜下行腹腔内粘连松解、采用腔内缝合器固定补片来修补造口旁疝是一种安全、有效的微创方法,值得临床推广应用.     

Mesh erosion into caecum following laparoscopic repair of inguinal hernia (TAPP): a case report and literature review

Repair of inguinal hernia is the most commonly performed surgical procedure. Both open and laparoscopic methods are accepted modalities of surgical treatment. Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) are the two types of laparoscopic repair of the inguineal hernia. The main advantages of laparoscopic repair, as compared to open repair, are a shorter hospital stay and a quicker recovery to normal activities. However, laparoscopic repairs are associated with a higher incidence of visceral and vascular injuries. One particular complication is the migration and erosion of mesh into the adjacent viscera. Although the total numbers of cases are small, compared to the total numbers of inguinal hernia repairs, they are important, as they often presented with a diagnostic dilemma. Most of the mesh migrations reported in the literature involves the urinary bladder. In this paper, we present a case of erosion of mesh into the caecum. The patient (a 66-year-old male) underwent TAPP repair of a right inguinal hernia in 1996 with polypropelene mesh. He also underwent an open appendicectomy in 1980. During the laparoscopic repair, he was found to have multiple intra-abdominal adhesions. He presented with intermittent diarrhea, for which he was investigated, and a benign caecal lesion was found. He was initially managed conservatively. However, his symptoms persisted and he underwent a right hemicolectomy in February 2006 in our hospital. The offending lesion was found to be the prolene mesh having eroded into the caecum.     

Laparoscopic repair of large hiatal hernia with polytetrafluoroethylene

Background: Several studies have shown that large hiatal hernias are associated with a high recurrence rate. Despite the problem of recurrence, the technique of hiatal herniorrhaphy has not changed appreciably since its inception. In this 3-year study we have evaluated laparoscopic hiatal hernia repair in individuals with a hernia defect greater than 8 cm in diameter. Methods: A series of 35 patients with sliding or paraesophageal hiatal hernias was prospectively randomized to hiatal hernia repair with (n= 17) or without (n= 18) polytetrafluoroethylene (PTFE). All patients had an endoscopic and radiographic diagnosis of large hiatal hernia. Both repairs were performed by using interrupted stitches to approximate the crurae. In the group randomized to repair with prosthesis, PTFE mesh with a 3-cm ``keyhole' was positioned around the gastroesophageal junction with the esophagus through the keyhole. The PTFE was stapled to the diaphragm and crura with a hernia stapler. Results: Patients were followed with EGD and esophagogram at 3 months postoperatively, and with esophagogram every 6 months thereafter. Individuals with PTFE had a longer operation time, but the 2-day hospital stay was the same in both groups. The cost of the repair was $1050 ± $135 more in the group with the prosthesis. There were two complications (1 pneumonia, 1 urinary retention) in the group repaired with PTFE and one complication (pneumothorax) in the group without prosthesis. The group without PTFE was notable for three (16.7%) recurrences within the first 6 months of surgery. Conclusion: On the basis of these preliminary results it appears that repair with PTFE may confer an advantage, with lower rates of recurrence in patients with large hiatal hernia defects. Received: 1 May 1998/Accepted: 22 December 1998     

The safety of biologic mesh for laparoscopic repair of large,complicated hiatal hernia

Background  

Biologic mesh is widely used for repair of large, complicated hiatal hernias. Recently, there have been reports of complications after its implantation. We studied the course of a large group of patients who had undergone hiatal hernia repair with use of biologic mesh to determine the rate of immediate and late complications related to its use.     

腹腔镜食管裂孔疝修补术的初步探讨

目的探讨腹腔镜食管裂孔疝修补和胃底折叠术（Toupet手术）治疗食管裂孔疝的临床效果。方法 2009年1月～2010年5月,21例患者行腹腔镜食管裂孔疝（Ⅰ型9例,Ⅱ型4例,Ⅲ型6例,Ⅳ型2例）修补,采用单纯缝合膈肌脚,补片完全缝合,补片缝合加钉合等方法修补食管裂孔疝,并同期行部分胃底折叠术。结果本组患者手术均获成功,手术时间85～170min。无中转开腹及死亡病例。术后平均住院7d。术后随访1～16个月,20例临床症状完全消失,1例改善不明显,无明确复发病例。结论腹腔镜食管裂孔疝修补和胃底折叠术安全有效,应根据患者情况采用个体化的修补方式。     

Mesh fixation in laparoscopic repair of ventral hernia: a new method

During laparoscopic repair of ventral hernia, optimal fixation of the prosthetic mesh to the abdominal wall includes transfascial fixation with sutures in addition to fixation with a stapling, clipping, or tacking device. With the current methods, intracorporeal passage grasping and retrieval of sutures from the abdominal cavity are technically difficult. The reason for this difficulty is the lack of three-dimensional visual feedback during conventional laparoscopy. An easier method is needed. A new method using T-shaped anchors (T-anchors) is described. A T-anchor is a horizontal bar made of rigid titanium that is attached to a vertical limb made of monofilament suture. T-anchors are deployed in pairs, through a needle, and are tied over a musculofascial bridge to achieve transfascial fixation of the mesh to the abdominal wall. This method eliminates the need for intracorporeal grasping and retrieval of the sutures.     

Mesh shift following laparoscopic ventral hernia repair

IntroductionTraditionally, laparoscopic ventral hernia repair (LVHR) is performed by placing the trocars on one side of the abdomen. Tacking the mesh on the operative side can be challenging. We hypothesized that mesh shift may occur as a result of this approach. We define mesh shift as any mesh off-center, where the center is the hernia defect. Our objectives were to evaluate whether mesh shift occurs after LVHR, and to develop a grading system to describe this phenomenon.MethodsWe conducted a retrospective review of patients who underwent LVHR from 2000 to 2010. We examined patient demographics, comorbidities, radiographic data, surgical data, and outcomes. Using analysis of variance, we analyzed continuous data; we used Chi squared to analyze categorical data. Of the 201 patients, we reviewed 78 postoperative computed tomography (CT) scans. Two surgeons measured mesh overlap of the fascia bilaterally at the level of the hernia defect. We compared a ratio of the two sides of overlap (least overlap/greatest overlap) and classified patients into four grades: grade I, no mesh shift (ratio of 0.5–1.00); grade II, mild mesh shift (ratio of 0.20–0.49); grade III, moderate mesh shift (>0–0.19); and grade IV, major mesh shift with recurrence (<0). Any recurrence was classified as a grade IV shift.ResultsA total of 48% of patients had mesh shift (grade II = 23%; grade III = 10%; and grade IV = 17%). In 92% of the patients with mesh shift, the mesh migrated away from the port placement site, resulting in decreased mesh/fascial overlap. Patients in the four groups had similar demographics, comorbid conditions, hernia characteristics, operative technique, and outcomes (excluding recurrences, which were all grade IV by definition). Whereas differences in time to follow-up CT scan in the different grades were not statistically significant, there was a trend toward increasing shift with time (mean: grade I, 20 mo; grade II, 38 mo; grade III, 50 mo; and grade IV, 26 mo; P = 0.07). A total of 26 patients (33%) had multiple postoperative CT scans. With time, it appears that mesh tended to shift with time (grade I, 68%–46%; grade II, 12%–19%; grade III, 12%–8%, and grade 4, 8%–23%).ConclusionsMesh can shift from the ideal central placement after LVHR. Mesh tends to shift away from the operative side and recurrences tend to occur on the operative side. Mesh shift may be a precursor to hernia recurrence. Recurrence may be a two-step process, beginning first with intra-operative mesh shift followed by additional factors (such mesh contraction) that may accentuate the shift and lead to recurrence. Potential solutions include increasing mesh overlap (≥6 cm), performing transcutaneous closure of central defect, securing trans-fascial sutures before tacking, placing operative side tacks first, and consider placing contralateral ports to secure the mesh.     

Mesh crural repair of large paraesophageal hiatal hernias.

Surgical repair is indicated in patients with paraesophageal hernias but is associated with a high recurrence rate. Our objective was to assess the safety and efficacy of mesh reinforcement of the crural closure in laparoscopic paraesophageal hernia repair. We conducted a 7-year retrospective review of all patients undergoing laparoscopic paraesophageal hernia repair with or without use of mesh. The main outcome measures were use of mesh, reason for use, age, sex, preoperative symptoms, length of operation, length of hospital stay, postoperative complications, and long-term follow-up conducted by physician interview. Twelve patients were repaired with mesh (Group A) and 12 without (Group B). Age, sex, operating time, length of hospital stay, and postoperative complications were similar in both groups. In Group A two patients required an interposition graft and ten required mesh reinforcement of the crural closure. One Group A patient developed an early recurrence requiring a reoperation, and one Group B patient developed a gastric leak where the fundus was sutured to the crura. The remainder of the patients experienced resolution of their symptoms at 2 weeks follow-up. Long-term follow-up (average 37 months) showed one Group B patient with a recurrence of reflux symptoms, but an upper gastrointestinal study showed no recurrence of hernia. All others remained asymptomatic. We conclude that the use of mesh in laparoscopic repair of large paraesophageal hernias appears safe and may reduce recurrence.