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2011;213(4):461–8.
44. Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt
M, Sheppard B, etal. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair:
a multicenter, prospective, randomized trial. Ann Surg.
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409
Mesh Technology
inHiatal Hernia
FerdinandKöckerling, BeatMüller-Stich, andBruceRamshaw
39.1 Suture Versus Mesh Repair – 410
39.2 Complications ofMesh Implantation – 410
39.3 Biologic Versus Synthetic Meshes
Versus Suture – 410
39.4 Risk-Benet Analysis forMesh
Augmentation – 411
References – 413
39
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_39
410
F. Köckerling et al.
39
39.1 Suture Versus Mesh Repair
Laparoscopic repair of large hiatal hernias is associated with high recurrence rates [1]. In the Society
of American Gastrointestinal and Endoscopic
Surgeons (SAGES) Guidelines for the management of hiatal hernia [2, 3] is stated on the basis of
a moderate level of evidence that the use of mesh
for reinforcement of large hiatal hernia repairs
leads to decreased short-term recurrence rates.
ere is inadequate long-term data on which to
base a recommendation either for or against the
use of mesh at the hiatus [3].
In the meta-analysis of Antoniou etal. [4], three
randomized controlled trials reporting the outcome
of 267 patients were identied. e follow- up period
ranged between 6 and 12 months. e weighted
mean recurrence rates aer primary and mesh-reinforced hiatoplasty were 24.3% and 5.8%, respectively.
In the meta-analysis of Memon et al. [5], 4
RCTs were analyzed, totaling 406 patients
(suture= 186, prosthesis=220). For only one of
the four outcomes, i.e., reoperation rate (OR 3.73;
95% CI 1.18; 11.82; p=0.03) did the pooled eect
size favor prosthetic hiatal herniorrhaphy over
suture cruroplasty. For other outcomes, comparable eect sizes were noted for both groups which
included recurrence of hiatal hernia or wrap
migration, operating time, and complication rates.
In a systematic review by Furnée et al. [6], 26
studies were included. Laparoscopic hiatal hernia
repair was performed with mesh in 924 patients and
without mesh in 340 patients. e type of mesh used
was very dierent: polypropylene in six, biomesh in
nine, polytetrauoroethylene (PTFE) in two,
expanded PTFE (ePTFE) in two, and composite
polypropylene-PTFE in another two. Radiological
and/or endoscopic follow-up was performed aer a
mean period of 25.2±4.0months. ere was no, or
only a small, recurrence <2 cm in 385 of the 451
available patients (85.4%) in the mesh group and in
182 of 247 (73.7%) in the non-mesh group.
In a meta-analysis of Müller-Stich et al. [7], 3
RCTs and 9 observational clinical studies (mesh
types: PTFE, biological, polypropylene, composite)
including 915 patients with paraesophageal hernia
repair revealed a signicantly lower recurrence rate
for laparoscopic mesh-augmented hiatoplasty
(pooled proportions, 12.1% vs 20.5%; odds ratio
0.55 [0.34–0.89]; p=0.04). e authors concluded
that mesh application should be considered for
laparoscopic paraesophageal hernia repair.
In a further systematic review and metaanalysis, Tam etal. [8] identied 13 studies with
1194 patients, 521 with suture and 673 with mesh
repair. Odds of recurrence (OR 0.51; 95% CI 0.30–
0.87; overall p=0.014) but no need for reoperation (OR 0.42; 95% CI 0.13–1.37; overall p=0.149)
were less aer mesh cruroplasty. e authors concluded that the quality of evidence supporting
routine use of mesh cruroplasty was low.
39.2 Complications ofMesh
Implantation
Erosion and mesh migration are rare but devastating complications of synthetic mesh repair [1].
Stadlhuber et al. [9] reported about 17 cases of
intraluminal mesh erosion, esophageal stenosis in 6
cases, and 5 patients with dense brosis. e authors
concluded that complications related to synthetic
mesh placement at the esophageal hiatus were more
common than previously reported. Likewise, several case reports have drawn attention to severe
complications following the use of synthetic meshes
for hiatal hernia repair [10, 11]. Additionally, hiatal
mesh is associated with major resection at revisional operation [12]. In the meta-analysis of
Müller-Stich et al. [7], the complication rates of
laparoscopic mesh-augmented hiatoplasty and laparoscopic mesh-free hiatoplasty for paraesophageal
hernias were comparable (pooled proportions,
15.3% vs 14.2%, OR=1.02 [0.63–1.65]; p=0.94).
e systematic review of laparoscopic mesh-augmented hiatoplasty data yielded a mesh-associated
complication rate of 1.9% for those series reporting
at least one mesh-associated complication [7]. No
erosions, strictures, or dysphagia were identied on
follow-up aer 6, 45, and 58 months of using biological meshes [13, 14, 15], nor did a systematic
review nd evidence of any material-specic side
eects of biological meshes on using such biological
meshes for mesh-augmented hiatoplasty [16].
39.3 Biologic Versus Synthetic
Meshes Versus Suture
A prospective randomized trial did not nd any
signicant dierence in the recurrence rate
between the groups with suture repair vs absorbable mesh vs nonabsorbable mesh repair [17].
However, the sample size of around 40 patients
per group was relatively small.
Mesh Technology inHiatal Hernia
. Fig.39.1 Typical
clinical nding of a large
paraesophageal hernia
. Fig.39.2 Wide open
hiatus after reposition of
the stomach into the
abdominal cavity
411
39
One systematic review, which included metaanalysis [1], identied 5 relevant studies with 295
patients where short-term follow-up revealed a
suture repair recurrence rate of 16.6% vs 3.5% for
biologic mesh repair (p = 0.003). e limited
available information does not permit any conclusions about the long-term ecacy of biologic
meshes in this setting [1].
39.4 Risk-Benet Analysis forMesh
Augmentation
When performing hiatal herniorrhaphy, the
increased risk of recurrence without mesh must
be weighed against the potential risk of subsequent major resection when using mesh because
of erosion and mesh migration [9–12]. MüllerStich et al. [7] found that recurrences can be
bisected by mesh application from 20.5% to 12.1%
aer a follow-up period of approximately 3 years.
Mesh-associated complications are rare at a rate
of 1.9% and do not markedly contribute to overall
procedure-related complications. e reduction
from 20.5% to 12.1% aer use of mesh corresponds to an absolute risk reduction of 8.4% and
a number needed to treat 12 (95% CI, 10.6–13.5).
Reoperation rates aer “mesh use” and “no mesh
use” are 2.4% and 8.0%, respectively, and correspond with an absolute risk reduction of 5.6%
and a number needed to treat 18 (95% CI, 13.3–
27.3). e risk-benet analysis revealed an 11%
higher lifelong operation-related mortality rate of
1.6% for laparoscopic mesh-augmented hiatoplasty vs 1.8% for laparoscopic hiatoplasty (thinking of operation-associated mortality of very
risky reoperations), corresponding to an absolute
risk reduction of 0.3% and a number needed to
treat 344 (95% CI, 297.6–406.5). Even more interesting was that the rate of polypropylene-associated complications (0.8%) was lower than that of
biological- associated complications (1.3%) [7].
Other authors concluded [1, 16] that the severe
complications related to mesh erosion and
migration do not appear to occur on using biological meshes (. Figs.39.1, 39.2, and 39.3). On
412
F. Köckerling et al.
. Fig.39.3 Closing of the
hiatus with nonabsorbable
sutures
. Fig.39.4 A 12×8cm
Tutomesh is formed to a roll
39
. Fig.39.5 The Tutomesh
roll is sutured in a u-form to
the hiatal crus for augmen-
tation of the hiatoplasty
short- term follow-up, biological meshes were
found to also reduce the recurrence rate [1]. To
date, there is no sucient data available on the
longer-term follow-up outcome. On weighing up
the risks against the benets, the short-term data
available would seem to support the use of bio-
logical meshes for mesh-augmented hiatoplasty
in the case of large hiatal hernias. Further RCTs
should be carried out in the future with greater
sample sizes to conclusively determine which
meshes are more suitable for hiatal hernia repair
(. Figs.39.4, 39.5, and 39.6).
Mesh Technology inHiatal Hernia
. Fig.39.6 Final view to
the Tutomesh augmentation of the hiatoplasty
413
39
References
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augmentation of the diaphragmatic hiatus with biologic
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Guidelines for the Management of Hiatal Hernia. Society of American Gastrointestinal and Endoscopic Surgeons. 2013. http:/www.sages.org.
4. Antoniou SA, Antoniou GA, Koch OO, Pointner R, Granderath FA. Lower recurrence rates after meshreinforced versus simple hiatal hernia repair: a
meta- analysis of randomized trials. Surg Laparosc
Endosc Percutan Tech. 2012;22(6):498.
5. Memon MA, Memon B, Yunus RM, Khan S.Suture Cruroplasty versus Prosthetic hiatal Herniorrhaphy for large
hiatal hernia: a meta-analysis and systematic review of
randomized controlled trials. Ann Surg. 2016;263(2):
258–66. https://doi.org/10.1097/SLA.000000000001267.
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M, Büchler MW, Fischer L.Use of mesh in laparoscopic
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Hunter JG, Demeester TR, Swanstrom LL, Smith D, Filipi
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11. De Moor V, Zalcman M, Delhaye M, El Nakadi I.Complications of mesh repair in hiatal surgery: about 3 cases
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12. Parker M, Bowers SP, Bray JM, Harris AS, Belli EV, Puke
JM, Preissler S, Asbun HJ, Smith CD. Hiatal mesh is
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M, Sheppard B, Jobe B, Polissar N, Mitsumori L,
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NJ, Sheppard BC, Polissar NL, Neradilek MB, Mitsumore LM,
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17. Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD,
Aly A, Gan S, Game PA, Jamieson GG. Laparoscopic
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https://doi.org/10.1097/SLA.0000000000000842.
Complications ofHiatal
Hernia Repair
andPrevention
Jelmer E.Oor, FerdinandKöckerling, RajeshKhullar,
andEric J.Hazebroek
40.1 Praxis in Detail, “How IDo It”,
Daily Routine Tips andTricks – 416
40.1.1 Introduction – 416
40.1.2 Intraoperative Complications – 416
40.1.3 Early Postoperative Complications – 416
40.1.4 Late Postoperative Complications – 416
40.1.5 Avoidance ofUrgent Surgery – 417
40.1.6 Laparoscopic Approach – 417
40.1.7 Leakage Following Esophageal Lengthening
Procedures – 418
40.1.8 Postoperative Care – 418
415
40
40.2 Is What I AmDoing Every Day
Evidence Based? – 418
40.2.1 Comments – 418
40.2.2 Comments – 419
40.2.3 Comments – 419
References – 419
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_40
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J. E. Oor et al.
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40.1 Praxis in Detail, “How IDo It”,
Daily Routine Tips andTricks
40.1.1 Introduction
Surgical correction of hiatal hernias (HH) is a
relatively safe procedure, with low reported mortality and morbidity rates [1, 2]. When complications do occur, however, they may signicantly
inuence the patients’ outcome and quality of life.
In this chapter, we describe the dierent types of
complications that may occur during and/or following HH repair and provide valuable tips and
tricks for the prevention and/or management of
these complications.
40.1.2 Intraoperative Complications
e most frequently reported complications during hiatal hernia repair include bleeding, capsular
tears of the liver or spleen, perforation of the
esophagus and/or stomach, and opening of the
pleura [1]. Intraoperative complications are frequently caused by dense adhesions causing confusing anatomy and diculties during the
dissection and resection of the hernia sac.
Especially large-type IV HHs, characterized by
the intrathoracic migration of abdominal contents, including the omentum, small intestine,
and colon, are associated with extensive intrathoracic adhesions near the mediastinum and pleura,
with the risk of damaging these and other structures during dissection.
Intraoperative bleeding can originate from the
hernia sac and hiatal pillars during resection of
the hernia sac or from iatrogenic lesions of the
liver and spleen. Iatrogenic esophageal perforation is a rare but potentially life-threatening complication, with severe consequences for patient
outcome. Placement of a bougie for adequate sizing of the hiatus and fundoplication wrap carries
the risk of iatrogenic esophageal perforation during the passage of the bougie, since this is performed without esophageal visualization by
others than the operating surgeon [3]. However,
this complication is extremely rare. Postoperative
upper gastrointestinal contrast series can be used
following dicult surgical procedures or bougie
placement in order to detect esophageal perforation at an early stage, followed by endoscopic
stenting of the esophagus.
40.1.3 Early Postoperative
Complications
Morbidity following HH repair is most commonly
caused by general postoperative complications,
including pneumonia, thromboembolic complications, and congestive heart failure. Procedure- spe cic
complications, such as esophageal leakage or early
hernia recurrence, occur much less frequently [1].
Dysphagia may occur at an early stage or
develop as a late complication following HH repair.
In case of early dysphagia, a wait-and-see policy
seems justied in order to rule out dysphagia
caused by early postoperative edema. In case early
dysphagia does not reside within several weeks to
months, with persistent obstructive symptoms
and/or dysphagia-like symptoms, dysphagia
caused by a wrap or cruraplasty that has been constructed too tight seems more likely. Postoperative
follow-up in patients with persistent dysphagia
should at least include upper gastrointestinal contrast series in order to rule out esophageal stenosis,
and upper gastrointestinal endoscopy and/or
esophageal manometry to rule out esophageal
aperistalsis. In patients suering from dysphagia,
special attention must be paid to the caloric intake,
since dysphagia may easily cause nutritional deciencies [4]. In case of esophageal stenosis, endoscopic pneumodilatation is a relatively safe and
feasible technique for improving dysphagia and
obstruction [5, 6]. Recurrent surgery is an option
that should be reserved for those patients in which
an objectied cause has been found and who do
not or insuciently respond to conservative or
endoscopic treatment, including pneumodilatation. In these patients, the risk of insucient
improvement of symptoms and the increased risk
of serious intraoperative morbidity should be well
balanced against the impact of recurrent symptoms for the patient.
40.1.4 Late Postoperative
Complications
Late postoperative complications include complications that are more specically associated with
HH repair. As stated before, dysphagia is a serious
and frequently reported problem, and recurrent
surgery should be reserved for a selected group of
patients in whom it seems likely that they will
benet from recurrent HH repair.
Complications ofHiatal Hernia Repair andPrevention
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40
A rare type of complication is caused by intestinal erosion of nonabsorbable mesh into the
stomach or esophagus [6, 7]. is is an unusual
complication; however, the consequences can be
devastating. 7 Chapter 39 specically focuses on
this and other complications associated with the
use of mesh during HH repair. One of the most
important preventative measures for this specic
type of complication is mesh placement in a noncircumferential u-shape while carefully avoiding
direct contact between the mesh and the stomach
and esophagus.
Recurrence of HH is another important complication. Since it has been demonstrated that
most recurrent HHs are relatively small and
(partly) asymptomatic, performing redo surgery
should be well reserved for those patients that suffer from a symptomatic and objectied HH and in
whom it is likely that functional outcome will
improve following recurrent repair [8]. e management of recurrent HH will be discussed in
more detail in 7 Sect. 41.2.
In the following section, we will provide several additional tips and tricks based upon our
own experiences in order to help prevent the
occurrence of both intra- and postoperative complications.
40.1.5 Avoidance ofUrgent Surgery
Acute or nonelective surgery should be avoided
whenever possible. Several studies have demonstrated increased mortality and morbidity rates
and longer hospitalization following acute surgical repair compared to elective surgery [9, 10]. In
case a patient presents with symptoms of acute
obstruction and there is a high suspicion of strangulation, urgent decompression using nasogastric
tube placement or endoscopic aspiration is usually sucient and provides time for scheduling
elective or semi-elective surgery under optimal
conditions [10]. Only when decompression is
unsuccessful, the patient is unstable, or there is
evidence for gastric ischemia and/or perforation
of the esophagus or stomach, urgent surgery
should be performed [11].
Patients with a history of HH and progressive
obstruction frequently suer from a suboptimal
nutritional status because of reduced dietary
intake. Decompression with subsequent preoperative nasogastric or parenteral feeding provides the
opportunity to optimize the patients’ nutritional
status, which could decrease the risk of perioperative complications. is also accounts for patients
suering from chronic obstructive pulmonary
disease (COPD), who could signicantly benet from preoperative pulmonary rehabilitation.
Especially in elderly patients, who frequently
suer from cardiac or pulmonary comorbidities,
surgery should be planned aer the patient has
visited the anesthesiologist, cardiologist, or pulmonologist, in order to optimize the conditions
under which the patient is operated.
40.1.6 Laparoscopic Approach
e introduction of laparoscopic abdominal surgery has signicantly improved patient outcome
in terms of reduced morbidity, postoperative
pain, and length of stay compared to conventional, open surgery. ese advantages have also
been demonstrated to account for laparoscopic
HH repair and antireux surgery [12]. Since
the introduction of laparoscopic paraesophageal hernia repair in 1992 by Concreve et al.
and Cuschieri etal., the laparoscopic approach
has replaced the conventional open approach,
with lower reported morbidity rates and shorter
hospitalization following laparoscopy, benets
that are particularly important in the treatment
of elderly patients [12–14]. Symptom resolution and reoperation rates seem to be similar
for laparoscopic HH repair and open surgery, a
fact that used to be a matter of debate [8, 15].
Furthermore, the laparoscopic approach provides enhanced access to the mediastinum,
thereby facilitating adequate dissection and excision of the hernia sac compared to conventional
surgery and reducing the risk of intraoperative
complications and early recurrence due to inadequate dissection.
Consequently, laparoscopy has now been
accepted as the standard approach for HH repair.
Despite a history of previous abdominal surgery,
laparoscopy should be the primary approach in all
patients. e conversion rate of laparoscopically
HH repair appears to be less than 2%, most
frequently caused by bleeding, perforation, adhesions, or inability to laparoscopically reduce the
hernia into the abdominal cavity [1]. e benets
of laparoscopic surgery, especially the lower morbidity rate, outweigh the risk of conversion.