Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair

Background: Although laparoscopic repair of type 3 paraesophageal hernias is safe and results in symptomatic relief, recent data have questioned the anatomic integrity of the laparoscopic approach. The reports document an asymptomatic recurrence rate as high as 42% with radiologic follow-up evaluation for type 3 paraesophageal hernias repaired laparoscopically. This disturbingly high recurrence rate has prompted the addition of an anterior gastropexy to our standard laparoscopic paraesophageal hernia repair. Methods: A prospective series of 28 patients underwent laparoscopic repair of large type 3 hiatal hernias between July 2000 and January 2002 at the Cleveland Clinic Foundation by one surgeon. All the patients underwent reduction of the hernia, sac excision, crural repair, antireflux procedure, and anterior gastropexy. They all had a video esophagram 24 h after surgery, then at 3-, 6-, and 12-month follow-up visits and annually thereafter. Symptomatic outcomes were assessed with a standard questionnaire at each follow-up visit. Results: In this study, 21 women and 7 men with a mean age of 67 years (range, 35–82 years) underwent successful laparoscopic paraesophageal hernia repair. The mean operative time was 146 min (range, 101–186 min), and the average blood loss was 71 ml (range, 10–200 ml). One intraoperative complication occurred: A small esophageal mucosal tear occurred during esophageal dissection and was repaired laparoscopically. At 24 h, upper gastrointestinal examination identified no leaks. At this writing, all the patients have undergone video esophagram at a 3-month follow-up visit. All were asymptomatic and all examinations were normal. Of the 28 patients, 27 have undergone follow-up assessment at 6 months. At this writing, all the patients have undergone video esophagram at 3, 6, and 12 months follow up visits. All were asymptomatic and all examinations were normal. Ten patients have completed 2 year follow up barium swallows with no recurrences. Conclusions: With up to 2 years of follow-up evaluation, the addition of an anterior gastropexy to the laparoscopic repair of type 3 hiatal hernias resulted in no recurrences. These encouraging results necessitate further follow-up evaluation to document the long-term effects of anterior gastropexy in reducing postoperative recurrence after laparoscopic repair of paraesophageal hernias.     

Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia

Background: We compared the incidence of early hernia recurrence in nonrandomized but consecutive patients undergoing laparoscopic repair of paraesophageal hernia (LRPH) without and with excision of the hernia sac. Methods: LRPH was completed in 55 of 58 patients. In the first 25 patients, the sac was not excised. Total sac excision was performed in the subsequent 30 patients. All patients had crural repair with or without fundoplication, or gastropexy. Results: Mean age of patients was 68 years (range, 34–95). There were three conversions; one patient died postoperatively. Mean operative time was 225 min in the first group and 190 min in the sac excision group. Median length of stay was 2 days (range, 1–15) for both groups. Conclusions: A precise method of total sac excision simplified dissection. It also ensured complete reduction of the hernia and availability of adequate esophageal length. Operative time was not increased, and no subsequent early recurrences were observed (p < 0.05). Received: 3 April 1997/Accepted: 18 July 1997     

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients. Received: 4 April 1998/Accepted: 9 December 1998     

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     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Emergency laparoscopic repair of a paraesophageal hernia

A 63-year-old male with a previously documented paraesophageal hernia presented with acute severe epigastric pain and bloating. He was taken urgently to the operating room for laparoscopic exploration. The hernia sac was reduced with difficulty owing to extensive adhesions and the incarcerated portion of the stomach was mottled and blue. After 10 min of observation the stomach began to resume a normal appearance. The anterior crura were approximated and an anterior gastropexy was performed. The patient was discharged on the 3rd postoperative day and has been asymptomatic since. Paraesophageal hernias with evidence of impending gastric necrosis can be approached laparoscopically as long as basic principles are observed.     

Laparoscopic repair of paraesophageal hernia

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias.Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38–81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy.The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165–430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.Presented at the annual meeting of the Society of American Gastro-intestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Laparoscopic management of large paraesophageal hiatal hernia

Background: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus. Methods: Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure. Results: Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death. Conclusions: Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.     

Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh

Background: Despite being one of the most exact indications, laparoscopic treatment of eventrations and ventral hernias is barely known among the array of laparoscopic techniques. Methods: A total of 60 patients were assigned at random over a 3-year period to two homogeneous groups to be operated on for major ventral hernias with mesh. Half of them were operated upon laparoscopically and the rest with open surgery. Early and longer-term complications were analyzed, as were operative time and postoperative hospital stays. Results: The two groups were homogeneous in terms of demographic and clinical characteristics. The group that was operated on laparoscopically presented a lower rate of postoperative and longer-term complications; similarly, surgery time was significantly lower (p < 0.05). Hospitalization time was also significantly lower than in the group undergoing conventional open surgery (p < 0.05). Conclusions: Laparoscopic treatment of postoperative eventration and primary ventral hernia reduces complications and relapse rates, eliminates reintervention through mesh infection, reduces operative time, and considerably shortens the hospital stay. Received: 22 December 1997/Accepted: 18 August 1998     

Laparoscopic tension-free repair of large paraesophageal hernias

The paraesophageal hernia is an unusual disorder of the esophageal hiatus that may be associated with life-threatening mechanical problems. Elective repair is recommended at the time the condition is diagnosed, and open surgery can be accomplished with a low incidence of complications. The option of performing these repairs through a laparoscopic approach may further reduce morbidity and recovery time associated with surgical intervention. The purpose of this report was to review available options for laparoscopic repair and to present our experience with a tension-free technique for large paraesophageal hernias. Three patients with large diaphragmatic defects had laparoscopic repairs using an expanded polytetrafluorethylene (PTFE) patch secured with intracorporeal suturing techniques. One of these patients also underwent laparoscopic Toupet fundoplication in conjunction with repair of the hernia. In the other two patients, the fundus was secured to the right diaphragmatic crus to reduce the potential for recurrence and minimize postoperative reflux symptoms. All patients underwent successful repair without perioperative complications and had excellent long-term results. Laparoscopic repair of paraesophageal hernias can be accomplished by a number of different reported techniques. The use of a tension-free repair with PTFE may be particularly suitable for large diaphragmatic defects. An antireflux operation may be added selectively depending on clinical circumstances.     

Incidence of incipient contralateral hernia during laparoscopic hernia repair

Background: In addition to its well-known benefits of decreased postoperative pain and shorter recovery time, laparoscopic hernia repair has the major advantage of allowing the surgeon to explore the side contralateral to the clinically diagnosed hernia. The purpose of this study was to evaluate the incidence of incipient unsuspected contralateral hernia during totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy and to analyze the risks and benefits of identifying these hernias at the time of the initial surgery. Methods: We did a retrospective review of the charts of all of the 724 male patients who underwent laparoscopic TEP repair of 958 groin hernias between September 1991 and September 1999. The initial clinical impression of the existence of unilateral or bilateral hernias was noted and compared to our operative findings. The same surgeon performed all the repairs. Exploration of the contralateral side was performed in a systematic fashion. A second mesh prosthesis was placed if a contralateral hernia was found. Results: Bilateral hernia repair was performed on 234 patients (32.3%). In 62 of them (11.2%), the contralateral hernia was diagnosed only at the time of the procedure. Operative time ranged from 14 to 185 min (median, 38.6). The operative time for the contralateral exploration ranged from 2 to 5 min (median, 2.8). The rate of complications was 4.1%, but no complications were directly related to the exploration of the asymptomatic side. Conclusion: Our study shows that a large number of inguinal hernias are undiagnosed by physical examination (11.2%). Systematic contralateral exploration using the TEP approach is safe and does not greatly increase the operative time. Early identification and repair of a contralateral hernia obviates the need for reoperation, reduces overall costs to the health care system, and eliminates any further work loss for the patient. Received: 24 November 1999/Accepted: 3 February 2000/Online publication: 8 May 2000     

The feasibility of laparoscopic extraperitoneal hernia repair under local anesthesia

Background: Laparoscopic preperitoneal herniorrhaphy has the advantage of being a minimally invasive procedure with a recurrence rate comparable to open preperitoneal repair. However, surgeons have been reluctant to adopt this procedure because it requires general anesthesia. Methods: In this report, we describe the technique used in the laparoscopic repair of inguinal hernias under local anesthesia using the preperitoneal approach. We also report our results with 10 inguinal hernias repaired using the same technique. Results: Ten patients underwent their primary inguinal hernia repairs under local anesthesia. None were converted to general anesthesia. Four patients received a small amount of intravenous sedation. Three patients had bilateral hernias. There were five direct and eight indirect hernias. The average operative time was 47 min. The average lidocaine usage was 28 cc. All patients were discharged within a few hours of the surgery. There were no complications. Follow-up has ranged from 1 to 6 months. There has been no recurrences to date. Conclusions: The extraperitoneal laparoscopic repair of inguinal hernia is feasible under local anesthesia. This technique adds a new treatment option in the management of bilateral inguinal hernias, particularly in the population where general anesthesia is contraindicated or even for patients who are reluctant to receive general or epidural anesthesia. Received: 22 July 1998/Accepted: 18 September 1998     

Technique and early results of outpatient laparoscopic mesh onlay repair of ventral herniasrid=""id=""Presented to the Canadian Association of General Surgeons at the 67th Annual Meeting of the Royal College of Physicians and Surgeons of Canada, Toronto, Ontario, September 1998

Background: This report describes the technique and early results of a simple outpatient laparoscopic ventral hernia repair. Methods: Data were gathered prospectively for all laparoscopic ventral hernia repairs from January 1996 to December 1997 at a 228-bed hospital. Prolene mesh was stapled to the peritoneal surface of the abdominal wall, leaving sac in situ and mesh uncovered. Patients were seen by the operating surgeon within 2 months, and by an impartial surgeon (J.S.) after 3 to 14 months (average, 7 months; median, 6 months). Results: Repairs involved 44 hernias with orifice sizes 2 to 20 cm in diameter, and an average area of 20 cm². Of these 44 hernias, 36 were postoperative and 8 primary. Furthermore, 20% were recurrent hernias. There were four conversions. The outpatient rate was 98%, with one readmission for ileus. The early recurrence rate was 5%. Conclusions: Laparoscopic mesh onlay repair is a safe, easy, and effective procedure with minimal discomfort and a low early recurrence rate that can be performed safely on an outpatient basis. Received: 15 October 1998/Accepted: 18 October 1999/Online publication: 10 April 2000     

Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia?

Background: Giant prosthetic reinforcement of the visceral sac (GPRVS), an open preperitoneal mesh repair, is a very effective groin hernia repair. Laparoscopic transabdominal preperitoneal repair (TAPP), based on the same principle, is expected to combine low recurrence rates with minimal postoperation morbidity. Methods: Seventy-nine patients with 93 recurrent and 15 concomitant primary inguinal hernias were randomized between GPRVS (37 patients) and TAPP (42 patients). Operating time, complications, pain, analgesia use, disability period, and recurrences were recorded. Results: Mean operating time was 56 min with GPRVS versus 79 min with TAPP (p < 0.001). Most complications were minor, except for a pulmonary embolus and an ileus, both after GPRVS. Patients experienced less pain after a laparoscopic repair. Average disability period was 23 days with GPRVS versus 13 days with TAPP (p= 0.03) for work, and 29 versus 21 days, respectively (p= 0.07) for physical activities. Recurrence rates at a mean follow-up of 34 months were 1 in 52 (1.9%) for GPRVS versus 7 in 56 (12.5%) for TAPP (p= 0.04). Hospital costs in U.S. dollars were comparable, with GPRVS at $1,150 and TAPP at $1,179. Conclusions: Laparoscopic repair of recurrent inguinal hernia has a lower morbidity than GPRVS. However, laparoscopic repair is a difficult operation, and the potential technical failure rate is higher. With regard to recurrence rates, the open preperitoneal prosthetic mesh repair remains the best repair. Received: 14 April 1998/Accepted: 28 May 1998     

Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy

Background: Although the recurrence rate for endoscopic herniorraphy is low (0–3%), it is still debatable whether these recurrences should be corrected laparoscopically or by the conventional method. The aim of this study was to investigate whether these recurrences can be repaired by means of the laparoscopic approach with acceptable complication and recurrence rates. Methods: From October 1992 to December 1997, 34 patients with recurrent inguinal hernias at physical examination underwent surgery at our institutions. All the recurrences occurred following endoscopic inguinal hernia repair with mesh prostheses. The recurrences were repaired endoscopically using a transabdominal approach. Depending on the size of the defect, a new polypropylene mesh was used. Results: Mean surgery time was 69 min. There were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Conclusion: The transabdominal preperitoneal approach is a reliable technique for recurrent inguinal hernia repair after previous endoscopic herniorrhaphy. Received: 7 September 1998/Accepted: 13 October 1998     

Short-term outcome of laparoscopic paraesophageal hernia repair

Background: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). Methods: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. Results: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1.7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. Conclusions: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair. Received: 24 July 1996/Accepted: 20 November 1996     

Prospective, multicenter study of laparoscopic ventral hernioplasty

Background: A standard technique for laparoscopic ventral hernioplasty (peritoneal onlay using an expanded polytetrafluoroethylene [ePTFE] patch for hernias ≥4 cm²) is being used in a prospective, multicenter, long-term study. Methods: Demographic, operative, and postoperative data were collected and analyzed. Follow-up clinical evaluations were conducted 7–10 days, 4 weeks, 6 months, 1 year, and then annually after surgery in all patients. Results: In the first 2 years of the study, 144 patients were enrolled; nine were lost to follow-up. The mean operating time was 120 min. The mean follow-up was 222 days (range 5–731). Postoperative complications were five infections, three cases of prolonged ileus, one bowel obstruction, 23 seromas (15 resolved without intervention), and six hernia recurrences. Hospital discharge occurred a mean of 2.3 days after surgery and return to normal activity a mean of 15 days postoperatively. Conclusions: Laparoscopic prosthetic ventral hernioplasty avoids the large wound required in open repairs, with attendant complications and recurrences, and appears safe, especially if an ePTFE mesh is used. Compared with conventional open ventral hernioplasty, the laparoscopic technique may also allow shorter hospitalization and a quicker return to normal activities after surgery. Received: 3 April 1997/Accepted: 10 August 1997     

Laparoscopic sleeve gastrectomy: an alternative for recurrent paraesophageal hernias in obese patients.

BACKGROUND: Recurrent paraesophageal hernias in obese patients are technically challenging and have a high recurrence rate. We sought to develop an alternative to the traditional approaches for this problem. This article describes the use of a sleeve gastrectomy in an obese patient with a large recurrent paraesophageal hernia. CASE REPORT: A morbidly obese 70-year-old woman presented with a 1-year history of chest pain, cough, dysphagia, and dyspnea. She had undergone an open paraesophageal hernia repair 8 years earlier. Diagnostic workup revealed a recurrent large paraesophageal hernia. Laparoscopically, we took down all adhesions, excised the hernia sac, reduced the stomach and distal esophagus into the abdomen, and closed the hiatus. We then resected the greater curvature and fundus of the stomach, leaving the lesser curve in a sleeve configuration. Eighteen months after the operation, the patient's chest pain, cough, dyspnea, and dysphagia were resolved. In addition, she has lost 57 pounds (255 to 198). CONCLUSION: A sleeve gastrectomy is a potentially useful alternative to fundoplication or gastropexy, or both of these, in the treatment of obese patients with complex paraesophageal hernias.     

360° laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease

Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux disease (GERD) and/or hiatal hernia. However, a relatively high incidence (7–11%) of intrathoracic Nissen valve migration/paraesophageal hernia following laparoscopic fundoplication has recently been reported. Methods: Between November 1992 and August 1995, 65 consecutive patients with severe GERD and/or hiatal hernia underwent laparoscopic 360° fundoplication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen valve migration had occurred within 4 months. Six of these patients were symptomatic and were again submitted to the laparoscopic intervention. Videotapes of both the first and second operation were reviewed. In all cases, it was apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the right crus were disrupted, probably due to the tension between the suture margins during the inspiratory movements of the diaphragm. These findings prompted us to perform an effective tension-free closure of the hiatus. A polypropylene mesh (3 × 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 on the lateral sides of the right and left cruses). Results: Between August 1995 and February 1998, the technique, complete with 360° fundoplication, was used for 67 patients with GERD. At mean follow-up of 22.5 months (range, 1–30), there was no evidence of postoperative paraesophageal hernia or complications related to the use of the mesh. Conclusions: This tension-free hiatoplasty seems to be an effective solution to prevent postoperative paraesophageal hernia in patients undergoing antireflux laparoscopic surgery. However, longer follow-up is still needed. Received: 9 July 1998/Accepted: 19 April 1999     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

Background: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). Methods: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. Results: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. Conclusions: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced. Received: 10 June 1997/Accepted: 6 October 1997