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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
396
B. Müller-Stich et al.
. Table38.2 Recommendations on dierent steps of hiatal hernia repair with the according level of evidence
and grade of recommendation
Surgical step Authors’ recom-
mendation (2017)
Complete excision of
hernia sac
Division of short gastric vessels
Extent of division of
short gastric vessels
Vagal nerve preservation
Type of cruroplasty Anterior or
Fundoplication Yes 1b/A No, in case of no
Type of fundoplication Partial fundoplica-
Mesh augmentation Yes
Mesh material Synthetic
Mesh xation Anteriorly, glue;
Yes 3b/C Yes 3b/C
Yes – No (if tension-free
Limited dissection – No recommendation –
Yes 3b/C No recommendation –
posterior
tion (or short
Nissen)
‡
§
Posteriorly, glue/
tacks/suture
Level of
evidence/grade
of recommen-
*
dation
1b/A Anterior or posterior 1b/A
†
1a/A
1a/A No recommendation –
4/C No recommendation –
4/C No recommendation –
SAGES recommendation (2013)
fundoplication is
possible)
reux history
Partial fundoplication (or short Nissen)
Level of evidence/
grade of
recommendation
1a/A
–
†
1a/A
*
38
*
In case of diering recommendations, only the highest level of evidence available is shown next to the referring
recommendation
†
Referrers to the preference of a partial fundoplication
‡
In large hiatal hernias (>5cm)
§
No PTFE
(>10cm) by Watson etal., a 40% conversion rate to
an open procedure in the rst 40 patients with
incomplete hernia sac dissection was reported.
e main reason for conversion was an impossible
safe mobilization of the esophagus without dissec-
tion of the hernia sac. e conversion rate dropped
In conclusion a complete dissection and excision
of the hernia sac can be recommended from the
available literature. e complete dissection and excision allow for a better visualization and mobilization
of the esophagus and a tension-free positioning of the
stomach within the abdominal cavity (. Table38.2).
to 9% in the next 46 patients when a complete dissection of the hernia sac was performed (p<0.001).
e authors concluded that the change of strategy
to a full dissection was the main reason for the
38.2 Division ofShort
Gastric Vessels
improved laparoscopic success rate and recommend it for an improved mobilization of the
esophagus and an adequate assessment of the
esophageal length [54].
e SAGES Guidelines on the treatment of gastroesophageal reux disease recommend that if
the fundus can be wrapped around the esophagus
Techniques ofHiatal Hernia Repair
. Fig.38.2 Complete mobilization and excision of the
hernia sac allow for optimal orientation at the hiatus,
decreasing the risk of injuries to the esophagus
without signicant tension, no division of the
short gastric vessels is needed. e level of evidence on this topic is high. If a tension-free fundoplication cannot be accomplished, division of
the short gastric vessels should be undertaken;
this recommendation is made on moderate quality of evidence. However, no recommendation on
the extent of the division of the short gastric vessels is made. Furthermore, the guidelines especially note that expert opinion in North America
advocates for the routine division of the short
gastric vessels to minimize tension (. Table38.2).
Five randomized controlled trials with various follow-up periods investigating the eect
of a division of the short gastric vessels in antireux surgery exist [3, 7, 12, 26, 56]. In a recent
meta-analysis by Markar et al. including the ve
available randomized controlled trials, no dierence regarding requirement for reoperations and
presence of postoperative dysphagia or reux was
shown. However, division of the short gastric
vessels was associated with a longer duration of
the operation (mean dierence 25.6min, 95% CI
14.18–37.05; p<0.001) and a reduced postoperative lower esophageal sphincter pressure (mean
dierence−3.69 mmHg, 95% CI –4.11 to –3.26;
p<0.001). No dierence in length of hospital stay,
postoperative complications, gas bloat syndrome,
or DeMeester score was found [29]. e extent of
division of the vessels varied greatly from two to
four short gastric vessels to the division of all short
gastric vessels, and this heterogeneity was not
taken into account in the meta-analysis. Clinical
397
studies comparing a limited with an extensive
division of the short gastric vessels during fundoplication are not existing. From two of the randomized controlled trials, 10–12-year follow-up
data is available on 170 patients [3, 62]. No dierence in dysphagia, heartburn, ability to belch or
vomit, and use of antisecretory medications was
observed. But division of the short gastric vessels was associated with a higher rate of bloating
symptoms (72% versus 48%, p=0.002) [11].
Since an extensive division of short gastric
vessels seems at most to be associated with
impairment of the clinical outcome, it cannot be
routinely recommended. However, a limited dissection of the short gastric vessels might be helpful for a tension-free fundoplication (. Table38.2).
38.3 Preservation ofthe
Vagus Nerve
No SAGES Guidelines are available concerning
the preservation of the vagus nerve in hiatal hernia repair. e quality of evidence on the topic is
low, and data concerning vagotomy in hiatal hernia repair is limited (. Table38.2).
e vagus nerve is responsible for the parasympathetic control of the digestive tract and
enhances gastrointestinal motility. e bers of
the nerve run over an anterior and a posterior
branch on the le and right side of the esophagus
to the stomach. e parasympathetic bers of the
vagus nerve innervate the stomach, kidney, pancreas, liver, gallbladder, and intestine till Cannon’s
point located in the le third of the colon transversum. e consequences of injury to the nerve
or a full denervation are still not fully understood;
however post vagotomy syndrome summarizes
delayed gastric emptying, diarrhea, recurrent
ulceration, and gall stone formation by biliary stasis. It is oen stated that the vagus nerve should be
carefully preserved, but vagotomy may help in
mobilizing the gastroesophageal junction, and an
elongation of the esophagus of 3–4cm has been
reported aer vagotomy [10, 16, 21, 28, 59].
Follow-up data on this topic is limited to three
retrospective case series.
In the study by Vansant etal. on 311 patients
with a hiatal hernia, a vagotomy was performed in
159 patients and combined with an antireux
procedure and compared to 152 patients without
vagotomy. e incidence of diarrhea was twice as
38
398
B. Müller-Stich et al.
38
high in the vagotomized group (34% vs. 17%;
p < 0.005); dumping and nausea and vomiting
occurred more oen in vagotomized patients (7%
vs. 0%; p < 0.005 and 13% vs. 1%; p < 0.005,
respectively). Furthermore the incidence of longterm symptoms (>3months) was higher in the
vagotomy group (26% vs. 1%; p<0.005) [52].
In contrast Oelschlager etal. described their
experience in patients with large or recurrent hiatal hernias in whom aer extensive esophageal
mobilization the gastroesophageal junction could
not be made to reach the abdomen without tension. ey rst added a posterior vagotomy, and
if the mobilization was still insucient, an anterior vagotomy was additionally added. A comparison of 30 vagotomized patients and 72
nonvagotomized patients showed no dierence
in severity of heartburn, regurgitation, abdominal pain, dysphagia, chest pain, bloating, nausea,
and diarrhea. However, vagotomy resulted in a
lower acid exposure. e authors concluded that
a unilateral vagotomy in contrast to bilateral
vagotomy did not increase the incidence of
dumping syndrome [45].
In the study by Trus etal., three vagal injuries
were reported in 76 patients with a paraesophageal hernia repair. Two of the patients had signicant gastric atony. One underwent laparoscopic
pyloroplasty the other partial gastrectomy and
Billroth II reconstruction. e third patient developed a gastric dilatation that resolved with nasogastric tube drainage [51].
If only a parietal cell vagotomy (PCV) was
added during a fundoplication, Jordan et al.
reported three advantages: First, PCV provided
permanent reduction in gastric acid secretion,
which is a cornerstone for the reux treatment.
Second, an excellent exposure of the gastroesophageal junction was provided aer PCV.ird, when
wrapping the esophagogastric junction, it seemed
more appropriate to penetrate the hepatogastric
omentum medial to the vagal nerve trunks, thereby
interrupting branches of the vagus nerves to the
parietal cell mass rather than penetrating the gastrohepatic omentum lateral to the nerve trunks
and invariably destroying the hepatic nerves. ey
performed a PCV in 188 patients without any gastric complaints in the follow-up [24]. ose ndings are further conrmed in a study of 49 patients
with gastric bandings where an anterior and posterior vagotomy was performed. At average followup of 5.7 years, none of the patients had
complications of gastric outlet obstruction or diarrhea. e authors concluded that the problem of
gastric outlet reported in other studies may be due
to chronic inammation and scarring in the region
of the pylorus due to existing ulcers or gastroesophageal reux disease and may not be caused
by vagotomy alone [30].
From the available data, it seems reasonable
that special care should be taken to keep the vagus
nerve intact during the dissection of the hiatal
hernia. If the mobilization of the esophagus seems
insucient, a posterior vagotomy may be added.
However, most commonly the esophagus can be
mobilized up to the tracheal bifurcation and
thereby lengthened into the abdomen without
vagotomy when the hernia sac is completely dissected (. Table38.2).
38.4 Cruroplasty
Cruroplasty is the crucial step during hiatal hernia repair and can either be performed anteriorly
or posteriorly. e SAGES Guidelines on the
treatment of gastroesophageal reux disease recommend with the grade “strong” and based on a
moderate level of evidence the closure of the crura
when the hiatal opening is large during antireux
surgery. Based on the ndings of one randomized
controlled trial in antireux surgery comparing
the ecacy of anterior versus posterior crural
repair, anterior crural closure may be associated
with less postoperative dysphagia (. Table38.2).
e study by Watson et al. on 102 patients
with gastroesophageal reux disease undergoing
laparoscopic Nissen fundoplication with anterior
and posterior cruroplasty found no dierence
between the groups in terms of postoperative dysphagia, heartburn, and overall satisfaction at
6 months follow-up. However, to achieve the
similar dysphagia rate, more patients in the posterior closure group had to undergo a second surgical procedure (15% vs. 0%; p=0.03) [58]. In many
reports on hiatal hernia repair, the type of cruroplasty was not specied. Some authors [1, 9, 16,
18, 20, 51] described a posterior closure, others
used either an anterior or posterior closure [10],
and others added an anterior suture selectively to
the posterior [41, 44, 55, 63].
In conclusion cruroplasty is the crucial step of
hiatal hernia repair. e type of cruroplasty
( anterior or posterior) seems to be of minor
ab
Techniques ofHiatal Hernia Repair
399
. Fig.38.3 a Symmetrically placed sutures for a posterior cruroplasty. b Completed cruroplasty without narrowing of
the esophagus
38
importance (. Table38.2). A tension-free repair
without deviation or narrowing of the esophagus
is essential. Furthermore care should be taken in
case of posterior cruroplasty that the crura are
approximated symmetrically (. Fig.38.3).
38.5 Fundoplication
e SAGES Guidelines recommend that a fundoplication must be performed during the repair of a
sliding hiatal hernia to address reux. For hiatal
hernias with paraesophageal involvement, a fundoplication is stated to be important as well, but based
on the data available at that time, a routine fundoplication is not recommended. Based on low-quality evidence and with the grade “weak,” the
guidelines recommend that in the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may not be necessary.
Regarding the type of fundoplication to be performed, there is a recommendation that the partial
fundoplication should be preferred due to less
postoperative dysphagia, fewer reoperations, a
similar patient satisfaction, and symptom control
of reux symptoms. e statement is based on a
high level of evidence. Due to limited long-term
follow-up data on the surgical eectiveness, no
strong recommendation is given because partial
fundoplication may be less eective in the long
term than a total fundoplication. It is strongly recommended to perform a partial fundoplication or
a short total fundoplication of 1–2cm over a large
56 French bougie (weak recommendation) to minimize postoperative dysphagia. e eectiveness of
the procedure is maximized with a total fundoplication or a longer (>3cm) posterior partial fundoplication (weak recommendation). It is further
noted that regional dierences in clinical practice
and expert opinion exist. Especially in North
America, total fundoplication is recommended by
experts due to concerns for the long- term eectiveness of other procedures (. Table38.2).
e SAGES Guidelines were published before
the study by Müller-Stich et al. was available, which
included 40 patients with a hiatal hernia with
paraesophageal involvement. e patients were
randomized to either mesh-augmented hiatoplasty
and cardiophrenicopexy (LMAH-C) or meshaugmented hiatoplasty with a fundoplication
(LMAH-F) (
a higher DeMeester score aer LMAH-C versus
LMAH-F was observed (40.9±39.9 vs. 9.6±17;
p=0.048). In line with these ndings, there was a
higher reux syndrome score at 12months in the
LMAH-C group (1.9±1.2 vs. 1.1± 0.4; p=0.020)
and a postoperative esophagitis rate of 53% versus
17% in favor of the patients with a fundoplication
(p=0.026) [34]. is data suggested that a hiatal
hernia repair should always be combined with a
fundoplication irrespective of the preoperative
evidence of GERD. Other authors [50, 60] also
supported the routine use of a fundoplication and
justied it with dierent arguments. e preoperative prevalence of gastroesophageal reux disease is high with up to 80% in patients with hiatal
. Fig.38.4). At 3months follow- up,
38
400
B. Müller-Stich et al.
. Fig.38.4 Laparoscopic mesh-augmented hiatoplasty
with Nissen fundoplication
hernias. Furthermore, an increased risk for reux
aer hiatal hernia repair was found in up to 30%
[34]. Second, the ability to reliably objectify reux
preoperatively is limited in case of paraesophageal
hernia due to anatomical reasons. If manometry
and pH testing is even possible, the results are difcult to be interpreted appropriately. Furthermore
an extensive dissection required for the hernia
repair predisposes for postoperative reux even in
patients with no previous reux history. Besides
the aforementioned reasons that support the routine use of an antireux procedure, fundoplication
is thought to support the anchoring of the cardia
below the diaphragm and might thereby reduce
the risk of recurrence. However, this hypothesis
could not be conrmed so far by the randomized
controlled trial by Müller-Stich et al., which may
be due to a limited sample size or a too short follow-up. Looking at the quality of life, Mittal etal.
compared patients undergoing hiatal hernia repair
with or without fundoplication. In the long term,
no dierence in quality of life was found [49]. Since
a routine fundoplication was shown to reduce
severe postoperative esophagitis [34] and quality
of life seems not impaired by a fundoplication [34,
49], routine use of fundoplication in hiatal hernia
repair should be recommended (. Table38.2).
Historical methods to anchor the cardia below
the diaphragm are the posterior gastropexy (Hill
repair), the fundophrenicopexy, and the round
ligament cardiopexy [22, 27, 39]. Although some
of these methods showed promising short-term
results, gastropexies are abandoned due to high
recurrence rates especially in times of minimally
invasive surgery [8]. erefore, from the current
point of view, fundoplication seems to be the only
eective method for durable prevention of postoperative reux.
e dierent types of fundoplication have been
extensively compared in randomized controlled
trials and in meta-analyses comparing the dierent fundoplications for the treatment of gastroesophageal reux disease. Varin et al. performed a
meta-analysis of 11 randomized controlled trials
comparing partial fundoplication to total fundoplication [53]. Total fundoplication resulted in a
higher incidence of postoperative dysphagia (OR
1.82–3.93; p < 0.001), gas bloat (OR 1.07–2.56;
p=0.02), and atulence (OR 1.66–3.96; p<0.001).
No dierence was found for the incidence of
esophagitis, heartburn, or persisting acid reux.
Of note is the signicantly higher reoperation rate
aer total fundoplication compared to partial fundoplication (OR 1.13–3.95; p=0.02). Furthermore,
no dierence was found in patient satisfaction. e
authors concluded that the partial fundoplication
was a safe and eective alternative to total fundoplication with potential advantages but called for
caution in interpreting the results due to the poor
quality of the included trials.
Broeders et al. performed a systematic review
and meta-analysis of total posterior fundoplication (Nissen) versus partial posterior fundoplication. Seven randomized controlled trials were
included in the analysis [4]. Total fundoplication
was associated with a higher postoperative prevalence of dysphagia (RR 1.61 (95% CI 1.06–2.44);
p=0.02), a higher reoperation rate (RR 2.19 (1.09–
4.40); p=0.03), a higher inability to belch (RR 2.04
(1.19–3.49); p=0.009), and more gas bloating (RR
1.58 (1.21–2.05); p<0.001). No dierences were
found for recurrent pathological acid exposure,
esophagitis, in-hospital complications, or patient
satisfaction. However, these results also should be
interpreted with caution since the largest study
included in the analysis by Strate etal. contradicted
to some ndings of the other included studies,
which favored total fundoplication particularly in
terms of acid exposure and esophagitis [48].
Broeders et al. furthermore performed a
systematic review and meta-analysis on laparoscopic 180° anterior hemi-fundoplication compared to the Nissen fundoplication including 5
Techniques ofHiatal Hernia Repair
401
38
randomized controlled trials with 458 patients
in total [6]. Operation time, in-hospital complication rate, and length of hospital stay were
similar in both groups. e prevalence of dysphagia with 15% versus 27% (RR 0.56, 95% CI
0.38–0.81; p=0.002) and severity of dysphagia
measured with the Dakkak dysphagia score (2.8
vs. 4.8; WMD −2.25; 95% CI −2.66 to −1.833;
p<0.001), gas bloating (11% vs. 18%; RR 0.59;
95% CI 0.36–0.97; p = 0.04), and inability to
belch (19% vs. 31% RR 0.63; 95% CI 0.40–0.99;
p=0.05) were lower aer the anterior hemi-fundoplication. Esophageal acid exposure, esophagitis, heartburn, dilatation rate and reoperation
rate, proton pump inhibitor use, lower esophageal sphincter pressure, and patient satisfaction
were similar aer the two procedures. Even at
5 years follow-up, the Dakkak dysphagia score
and the inability to belch remained lowered
aer laparoscopic anterior hemi-fundoplication. e study supports the use of an anterior
hemi- fundoplication for the treatment of gastroesophageal reux disease. However, it has to be
emphasized the investigated 180° anterior fundoplication is a complex procedure, which has to
be dierentiated from the much simpler Dor or
al fundoplication. According to Watson etal.,
with ve to six sutures, the fundus has to be
sutured to the right lateral wall of the abdominal
esophagus and the right crus as well as to the le
lateral wall of the abdominal esophagus and the
le crus.
In a third systematic review and metaanalysis, the group by Broeders et al. compared
the results of laparoscopic anterior fundoplication versus laparoscopic posterior fundoplication
[5]. Five randomized controlled trials of anterior
versus posterior total and two randomized controlled trials of anterior versus posterior partial
fundoplication were identied. In the short-term
follow-up of 6–12 months, esophageal acid exposure time (3.3% vs 0.8%; WMD 2.04; 95% CI
0.84–3.24; p <0.001), heartburn (21% vs 8% RR
2.71 95% CI 1.72–4.26; p<0.001), and reoperation rate (8% vs 4% RR 1.94 95% CI 0.97–3.87;
p=0.06) were higher aer laparoscopic anterior
fundoplication. However, the Dakkak dysphagia
score was lower aer laparoscopic anterior fundoplication (2.5 vs. 5.7 WMD −2.87 95% CI
−3.88 to −1.87 p<0.001). In the short-term fol-
low-up, no dierences were found for the prevalence of esophagitis, regurgitation, and the
perioperative outcome. During the long-term
follow-up of 2–10years, the higher rate of heartburn aer laparoscopic anterior fundoplication
persisted and was associated with a higher PPI
use rate. e reoperation rate in the long term
was twice as high aer anterior fundoplication
(10% vs. 5% RR 2.12 95% CI 1.07–4.21; P=0.03)
mainly due to recurrent gastroesophageal reux
disease. Dysphagia scores, inability to belch, gas
bloating, and patient satisfaction were not dierent in the long-term follow-up.
In conclusion all forms of gastropexy as single
treatment were abandoned due to high reux
recurrence rates. Since objectifying reux preoperatively is dicult in paraesophageal hiatal hernias, the prevalence of preoperative reux is high,
and hiatal hernia repair furthermore predisposes
for postoperative reux, repair for paraesophageal
hernias should be combined with a fundoplication to prevent postoperative reux. e available
data supports laparoscopic posterior fundoplication as the surgical treatment of choice. However,
it has to be considered that posterior partial fundoplication and an appropriate 180° anterior fundoplication are demanding procedures. ey
should be reserved to well-trained surgeons with
extensive experience with the method. Otherwise
a well-done Nissen fundoplication also can lead
to good results with high patient satisfaction,
maybe better than a badly done partial fundoplication. us, surgeons should perform the type of
fundoplication that they are familiar with.
Furthermore of note, little is known on the longterm eect of partial fundoplication in comparison with total fundoplication (. Table38.2).
38.6 Mesh Augmentation
e SAGES Guidelines state that insucient
long-term data is available, on which a recommendation could be based either for or against the
use of mesh at the hiatus (. Table38.2).
However, today, there is evidence that the use
of mesh for the reinforced repair of large hiatal
hernias (>5 cm) with paraesophageal involvement leads to a reduction of recurrences and consecutive reoperations at least in the midterm.
In a meta-analysis of four randomized controlled trials, Memon et al. compared primary
sutures (n = 186) with a prosthesis repair
(n=220). Mesh implantation led to a signicantly
402
B. Müller-Stich et al.
38
decreased reoperation rate (OR 3.73 95% CI
1.18−11.82, P=0.03), whereas no dierence was
found for operating time (SMD −0.46, 95% CI
−1.16 to −0.24, P=0.19) and complication rate
(OR 1.06, 95% CI 0.45−2.50, P = 0.90) [33]. A
recently published meta-analysis and risk-benet
analysis using a Markov Monte Carlo decisionanalytic model found even more arguments for
the routine placement of a mesh during the repair
of large hiatal hernias (>5cm). In 915 patients, a
bisection of recurrences from 20.5% to 12.1%
aer a follow-up of approximately 3 years was
found when mesh augmentation was compared to
suture repair alone. is corresponded to an absolute risk reduction for recurrences of 8.4% and a
number needed to treat of 12 (95% CI, 10.6–13.5)!
e reduction of recurrences was even more
prominent in a subgroup analysis restricted to
studies with follow-up periods longer than 2years
(mesh augmentation 11.5% vs. suture alone
25.4%; p = 0.007) and synthetic meshes (mesh
augmentation 9.9% vs. suture alone 19.0%;
p=0.005) [35]. Such a reduced risk of recurrence
leads to fewer reoperations as shown in a metaanalysis of only randomized controlled trials by
Memon et al. In the risk-benet analysis by
Müller-Stich etal., an absolute risk reduction of
5.6% and a number needed to treat of 18 (95% CI,
13.3–27.3) were shown regarding the reduction of
reoperations by mesh augmentation. is is an
important nding since reoperations at the hiatus
are risky and mortality is tenfold increased compared to primary surgery [61]. Furthermore, the
mesh-associated complication rate was surprisingly low with 1.9%. Consequently, mesh-associated complications did not lead to a signicantly
higher procedure-related complication rate (mesh
augmentation 15.3% vs. suture alone 14.2%). In
contrast, lifelong procedure- related mortality was
even reduced by mesh augmentation even with
the assumption that reoperations came along with
the same operative risk as primary operations
(mesh augmentation 1.6% vs. suture alone 1.8%).
is corresponded to an absolute risk reduction
of 0.3% and a number needed to treat of 344
regarding prevention of procedure-related mortality! (It has to be taken into account that this
calculation has been done assuming the same
mortality rate for reoperation as for primary surgery, which in fact is tenfold increased [61].
For mesh augmentation, dierent materials
can be used such as polypropylene, polyester,
polytetrauoroethylene, or biomaterial. Further-
more, meshes are categorized by their structural
specication such as weight, thickness, and pore
size. Both material and structural characteristics
have an inuence on the biological behavior of
meshes, which should be safe and stable. e ideal
mesh integrates quickly without the tendency to
migrate as shown for large porous polypropylene
in the study by Sen etal. [47].
In the meta-analysis by Müller-Stich et al.,
polypropylene has most commonly been used
(39.6% of all included patients) and was associated
with a low complication rate of 0.8%. e other
widely used meshes were polytetrauorethylene
(31.9% of all included patients) and biomeshes
(13.5% of all included patients) with reasonable
higher mesh-associated complication rates of
2.5% and 1.3%, respectively (. Fig.38.5) [2].
Polypropylene has thus been characterized
by strong tissue incorporation and strong adhesion formation. Polytetrauorethylene has been
associated with less adhesion formation and was
oen involved in clinical studies when erosions
of the esophagus were reported. A reason could
be the worse tissue integration that led to a more
mobile mesh. In the largest published series on
306 patients with a circular polypropylene mesh
of Müller-Stich et al., mesh-related complications
were found in 1% of patients (. Fig.38.6). Of note
no mesh migration or erosion of the esophagus was
observed [36]. e nding is further supported
by large animal studies where mesh shrinkage
of polypropylene meshes was correlated with an
enlargement of the mesh aperture for the esophagus. Taking these ndings into account, the fear
of stenosis aer application of a circular polypropylene mesh at the hiatus may thus be overestimated. Biomeshes from porcine small intestine
submucosa was introduced by Oelschlager et al.
because of the fear of possible complications by
synthetic meshes [42]. e mesh should temporarily reinforce the hiatal hernia repair during the tissue remodeling process. Aerward the
mesh was shown to be absorbed between 6 and
12months aer implantation, and thus the risk of
mesh-associated complications was estimated to be
reduced hypothetically. In their randomized controlled trial, Oelschlager etal. compared a primary
repair (n=57) to a primary repair with the biologic U-shaped mesh (n=51). e reason why they
used the U-shape was that they feared the amount
of brosis and traction that could lead to dysphagia
Techniques ofHiatal Hernia Repair
403
38
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
. Fig.38.5 Risk of mesh-associated complications
according to mesh material (Müller-Stich BP, Kenngott HG,
Gondan M, Stock C, Linke GR, Fritz F, etal. Use of mesh in
laparoscopic paraesophageal hernia repair: a metaanalysis and risk-benet analysis. PloS One.
. Fig.38.6 Circular polypropylene mesh placed around
the esophagus with a 56 French calibration tube in place
0.0%
(n=147)PP(n=2067)
0.8%
PG
1.3%
(n=621)
1.5%
Bio
(n=92)
postoperatively when using a circular mesh. At 6
months postoperatively, 12 patients (24%) in the
primary repair group and 4 patients (9%) in the
prosthesis group developed recurrent herniation
(p = 0.04) [44]. However, at 5 years follow-up,
59% in the primary repair group and 54% in the
biologic mesh group had a recurrent hiatal hernia
demonstrating that biomeshes are of no use in the
long-term prevention of recurrences (p=0.7) [43].
is nding was conrmed in a meta-analysis by
Antoniou SA etal., which focused on biomeshes
[2]. e use of biomeshes seems therefore to be
ineective for the repair of large hiatal hernias with
paraesophageal involvement.
11.1%
2.5%
Pgly
PTFE
(n=1622)
2015;10(10):e0139547). Comp. composite, DM dermal
matrix, PE polyethylene, PG polyglactine, PGly polyglycan,
PP polypropylene, PTFE polytetrauorethylene, SIS small
intestinal submucosa, NA not answered
3.1%
Comp.
(n=182)NA(n=216)PE(n=27)
3.2%
If a mesh is used, dierent shapes of meshes
have been proposed: strips and U-, A-, V-, and
circular-shaped. e dierent shapes have not
been compared in randomized controlled trials
so far. e mesh strips used by Ganderath etal.
were placed aer approximation of the crura with
nonabsorbable sutures. e 1 × 3 cm mesh was
placed posteriorly as an onlay mesh and secured
with a stich on each side. Dierent data is published. First, in a nonrandomized trial, patients
that underwent antireux surgery for gastroesophageal reux disease received either mesh
(n = 170) or primary suture (n=361) without
mesh for their hiatal closure. One year aer the
procedure, wrap migration was seen in 6.1% of
patients in the non-mesh group compared to
0.6% in the mesh group. However, dysphagia was
signicantly increased aer 3months in the mesh
group (35.3% vs. 19.8%), although aer 1year the
dysphagia rate of the two groups was equal (4.9%
vs. 4.4%) [20]. e second study was a randomized controlled trial including 100 patients with
gastroesophageal reux disease treated with a
360° Nissen fundoplication and either primary
suture repair or mesh-augmented repair. ree
months aer surgery, 10% of the patients in the
primary suture group compared to 2% of patients
in the mesh augmentation group were found to
have wrap migration. is number even increased
at 1-year follow-up to 26% of the patients with a
primary suture versus 8% of patients with mesh
38
404
B. Müller-Stich et al.
augmentation. As in the rst case series at
3months, the patients with a mesh augmentation
had a higher dysphagia rate (16% vs. 4%) that
decreased aer 12months to 4% in both groups
[19]. A similar mesh strip was applied in a randomized controlled trial by Watson etal., even
though they used a larger mesh measuring
2–3cm in height and 4–5cm in width. e study
compared three methods: suture repair (n=43)
vs. absorbable mesh (n=41) vs. nonabsorbable
mesh (n=42). A 92% follow-up rate at 12months
was achieved. A recurrent hernia was found in
23.1% aer suture repair, in 30.8% aer absorbable mesh, and in 12.8% aer nonabsorbable
mesh [57]. e clinical outcomes were similar.
Müller-Stich et al., Frantzides et al., and Szold
etal. used a circular mesh [13, 25, 36, 38]. Müller-
Stich et al. used a polypropylene mesh with an
outer diameter of 80mm and an eccentric hole of
18mm. As mentioned before, the circular polypropylene mesh was associated with a low meshrelated complication rate of 1% in 306 patients.
From clinical data and animal experiments, the
circular mesh was found to remain in a stable
position around the esophagus, which was
explained by a statistically centered repositioning
in case of every accidental mesh displacement.
Because of the circular form, every movement in
one direction could be followed by a countermovement until the nal integration into the
adjacent so tissue was completed. Another
explication for the stable position of circular
meshes by the authors was that the circular mesh
provided a large overlapping in the area around
the repaired hiatus. In theory the large overlapping of the mesh guaranteed the best possible
distribution of all involved forces. Frantzides
et al. used an oval polytetrauorethylene onlay
patch with a 3.5cm keyhole in the center of the
mesh. Seventy-two patients with large (>8 cm)
hiatal hernia were randomized to Nissen fundoplication with cruroplasty and to Nissen fundoplication, cruroplasty, and onlay mesh. At a
median follow-up of 2.5years, the primary closure group had a recurrence rate of 22% compared to 0% in mesh group (p<0.006) [14].
Since the esophageal hiatus is a very dynamic
area, dierent methods for mesh xation have
been proposed. A sucient xation is essential since mesh displacement can contribute to
recurrences or displaced meshes may erode into
adjacent structures like the esophagus, aorta,
. Fig.38.7 Fixation of a circular mesh at the hiatus with
a straight endostapler
stomach, or pericardium. Tack xation and suture
xation should be used with caution as they have
resulted in lethal cardiac and vascular injuries
(
. Fig.38.7) [15, 37]. Special caution should be
taken in the central tendon part of the diaphragm
where the thickness of the diaphragm averages
only 3 mm. Most of the injuries are caused by
helical tacks. Fixation with sutures may therefore be favored. However, sutures also can lead
to injuries of thepericardium [37]. Furthermore
intracorporal suturing at the hiatus remains a
dicult task contributing to a longer operative
time, so that mesh xation with brin glue has
been proposed recently. is way of xation may
especially be sucient when a large porous circular polypropylene mesh with fast tissue integration is chosen. e glue seeps easily through the
porous mesh to adhere to the underlying tissue.
is type of xation reduces the technical complexity of laparoscopic mesh xation. e risk
for cardiac or vascular injuries associated with
xation by sutures or tacks is eliminated. In the
available randomized controlled trials comparing
placement of mesh with primary suture, dierent
strategies for mesh xation were used: Ganderath
and Oelschlager secured the meshes with sutures.
Frantzides used straight tacks and Watson used
either sutures or tacks. No xation- related complications were reported in 220 patients from
those randomized controlled trials. No prospective trials comparing the dierent xation
strategies at the hiatus are available in humans.
Müller-Stich etal. reported two cases with a cardiac tamponade aer mesh xation, one with
Techniques ofHiatal Hernia Repair
405
38
helical tacks and one with sutures. e study
furthermore summarized dierent foreign cases
(n=7) with cardiac tamponade caused by hiatal
hernia surgery. Powell etal. used brin glue in 70
patients with paraesophageal or large sliding hernias. e mesh was placed and xed in an average
of 5 min. No complications were encountered.
Animal survival experiments were performed to
compare suture repair with brin sealant xation
for hiatal hernia repair. Despite the signicantly
reduced operative time (74.7 versus 127.0 min;
p < 0.01), no mesh migration, nor a dierence in cellular repopularization, or inammatory changes around the mesh were found aer
30 days [46]. e authors concluded that brin
sealants resulted in integration strength similar
to standard suturing. Dierent data was found
on ventral hernia repair, where meshes were xed
to the abdominal wall in a porcine and rabbit
model. In the experiment by Melman et al., the
acute xation strength was signicantly greater
for suture compared to tacking devices and to
brin sealants. Tacking devices were stronger
than brin sealants [32]. Jenkins as well found
an inadequate xation strength of brin sealants.
e xation strengths of suture plus brin sealants were equivalent or superior to the xation
strength of tacks alone [23].
In conclusion a mesh should always be
placed in large hiatal hernias (>5cm) with paraesophageal involvement since a positive eect
on the prevention of recurrences is proven and,
as a consequence, the need for complex reoperations is reduced. Risk-benet considerations
seem to benet mesh application since mesh
complications are rare and complex reoperations imply a higher lifelong mortality. When a
mesh is used, a quick integrating material such
as polypropylene should be considered.
Polytetrauorethylene should not be used due to
bad tissue integration characteristics, and biomeshes should be avoided due to missing longterm eectivity. Dierent forms of meshes can
be used. U-shaped and circular meshes seem to
have advantages due to their stability around the
esophagus. Mesh xation in the anterior tendinous half of the hiatus should be done with
brin glue, and in the posterior muscular half of
the hiatus brin glue, straight staplers or suture
xation can be applied. No staplers or sutures
should be placed in the anterior central tendon
part of the diaphragm (
. Table38.2).
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