Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
418
J. E. Oor et al.
40
40.1.7 Leakage Following
Esophageal Lengthening
Procedures
Postoperative leakage is a rare but serious
complication that most frequently occurs following esophageal lengthening procedures
for treating “short esophagus”, such as Collis
gastroplasty [1]. e phenomenon of “short
esophagus” will be discussed more in detail in
7 Chap. 41. Due to the serious consequences
of esophageal leakage, esophageal lengthening
procedures should be avoided as much as possible. Circumferential esophageal mobilization
and especially extended mediastinal mobilization are of vital importance in reducing axial
tension exerted on the hiatus, not only to prevent recurrent HH by providing a tension-free
position of the gastroesophageal junction in the
abdominal cavity, but also to provide adequate
length of the esophagus in order to prevent a
“short esophagus”. Esophageal lengthening procedures should be reserved for patients with a
history of Barrett’s esophagus with associated
esophageal shortening due to chronic esophageal damage, and the decision to perform this
procedure should be based upon intraoperative
ndings and adequate experience in performing these procedures [1].
40.1.8 Postoperative Care
As accounts for most types of surgery, early mobilization should be stimulated in order to prevent
postoperative morbidity, such as pneumonia and
thromboembolic complications. In patients with
known respiratory comorbidities, early postoperative vaporizing and chest physiotherapy help
prevent respiratory complications.
In order to prevent a sudden increase in intraabdominal pressure and subsequent disruption of
the HH repair, early postoperative gagging, belching, coughing, and vomiting should be treated
aggressively [4, 16, 17]. Nasogastric tube placement may be necessary to treat early gastric distension [4].
As stated before, postoperative upper gastrointestinal contrast series (UGIS) may be used for
early detection of iatrogenic esophageal perforation following dicult procedures or in patients
experiencing severe postoperative dysphagia.
However, there is insucient evidence to support
the routine use of postoperative UGIS [7].
40.2 Is What I AmDoing Every Day
Evidence Based?
e following recommendations, including available evidence, are adopted and modied from the
outcome of SAGES Guidelines Committee concerning the management of hiatal hernia [18].
Recommendations
5 Grade C: It is recommended that
postoperative nausea and vomiting
should be treated aggressively to
minimize poor outcomes
A sudden increase in intra-abdominal pressure is
thought to predispose to early anatomical failure
of the hiatal hernia repair [19]. It is suggested that
early postoperative gagging, belching, and vomiting are predisposing factors for anatomical failure
and the need for subsequent revision and therefore should mandate early and aggressive therapy
if they occur [19]. Gastric distension should be
recognized early, since it can be dangerous in the
immediate postoperative phase and can be treated
successfully by the placement of a nasogastric
tube or, in cases where an intraoperative gastrostomy tube was placed, by venting the stomach
through this tube [20, 21].
Recommendations
5 Grade D: Because early postoperative
dysphagia is common, attention should
be paid to adequate caloric and nutritional intake
40.2.1 Comments
With early postoperative dysphagia rates of up to
50%, the general recommendation is for slow
advancement of diet from liquids to solids.
Attention should be paid to adequate caloric and
nutritional intake in the postoperative period.
Expert opinion suggests that most patients will
Complications ofHiatal Hernia Repair andPrevention
419
40
lose 10–15 pounds (4.5–7kg) with laparoscopic
fundoplication and hernia repair followed by a
graduated diet from liquids to so solids. If dysphagia persists or weight loss occurs of more than
20 pounds (9kg), evaluation and intervention for
the dysphagia should be considered.
Recommendations
5 Grade B: Routine postoperative contrast
studies are not necessary in asymptom-
atic patients
40.2.2 Comments
ere are no studies supporting routine contrast
imaging aer hiatal hernia repair. If patients demonstrate symptoms of severe dysphagia or there is
a suspicion of a perforation, a contrast study is
indicated. Routine radiographic follow-up shows
a higher incidence of recurrence than symptomatic follow- up alone, but because most recurrences are small and asymptomatic, many suggest
that routine radiographic follow-up is not indicated [22, 23].
Recommendations
5 Grade B: Laparoscopic hiatal hernia
repair is as effective as open transab-
dominal repair, with a reduced rate of
perioperative morbidity and with a
shorter hospital stay. It is the preferred
approach for the majority of hiatal
5 hernias
40.2.3 Comments
Laparoscopic hiatal hernia repair results in less
postoperative pain compared to the open
approach. e smaller incisions of minimally
invasive surgery are less likely to be complicated
by incisional hernias and wound infection.
Postoperative respiratory complications are
reduced [24]. Results from multiple studies are
similar, with shorter hospital stay and less morbidity resulting from the minimally invasive
approach [25–36]. Recurrence rates are similar.
Conversion to open surgery is occasionally necessary for reasons such as bleeding, splenic injury,
or dense adhesions, and it is important that surgeons taking these on as laparoscopic procedures
are comfortable with an open repair should conversion become necessary.
References
Praxis in Detail, “How I do It”, Daily Routine Tips and Tricks
1. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe
BA, Landreneau RJ, Schuchert MJ. Outcomes after a
decade of laparoscopic giant paraesophageal hernia
repair. J Thorac Cardiovasc Surg. 2010;139(2):395–404.
2. Lidor AO, Steele KE, Stem M, Fleming RM, Schweitzer
MA, Marohn MR.Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia. JAMA Surg. 2015;150(5):424–31.
3. Edelman DS, Jacobs M, Lopez-Penalver C, Moses
K.Safe esophageal bougie placement for laparoscopic
hiatal hernia repair. JSLS. 1998;2(1):31–3.
4. Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis
D, Fanelli RD; SAGES Guidelines Committee. Guidelines for the management of hiatal hernia. Surg
Endosc. 2013;27(12):4409–28.
5. Gaudric M, Sabate JM, Artru P, Chaussade S, Couturier
D.Results of pneumatic dilatation in patients with dysphagia after antireux surgery. Br J Surg. 1999;86:1088–91.
6. Hui JM, Hunt DR, de Carle DJ.Esophageal pneumatic
dilatation for postfundoplication dysphagia: safety,
ecacy, and predictors of outcome. Am J Gastroenterol. 2002;97(12):972986–91.
7. Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ Jr,
Michael Brunt L, Hunter JG, Demeester TR, Swanstrom
LL, Daniel Smith C, Filipi CJ.Mesh complications after
prosthetic reinforcement of hiatal closure: a 28-case
series. Surg Endosc. 2009;23(6):1219–26.
8. Hazebroek EJ, Leibman S, Smith GS.Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair. Surg
Laparosc Endosc Percutan Tech. 2009;19(2):175–7.
9. Jobe BA, Aye RW, Deveney CW, Domreis JS, Hill
LD.Laparoscopic management of giant type III hiatal
hernia and short esophagus. Objective follow-up at
three years. J Gastrointest Surg. 2002;6:181–8.
10. Poulose BK, Gosen C, Marks JM, Khaitan L, Rosen MJ,
Onders RP, Trunzo JA, Ponsky JL. Inpatient mortality
analysis of paraesophageal hernia repair in octogenarians. J Gastrointest Surg. 2008;12(11):1888–92.
11. Jassim H, Seligman JT, Frelich M, Goldblatt M, Kastenmeier A, Wallace J, Zhao HS, Szabo A, Gould JC.A population-based analysis of emergent versus elective
paraesophageal hernia repair using the Nationwide
inpatient sample. Surg Endosc. 2014;28(12):3473–8.
420
J. E. Oor et al.
12. Light D, Links D, Grin M. The threatened stomach:
management of the acute gastric volvulus. Surg
Endosc. 2015;30(5):1847–52. [Epub ahead of print].
13. Weber DM. Laparoscopic surgery: an excellent
approach in elderly patients. Arch Surg. 2003;138:
1083–8.
14. Congreve DP. Laparoscopic paraesophageal hernia
repair. J Laparoendosc Surg. 1992;2(1):45–8.
15. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic
reduction, crural repair, and fundoplication of large
hiatal hernia. Am J Surg. 1992;163(4):425–30.
16. Mattar SG, Bowers SP, Galloway KD, Hunter JG, Smith
CD. Long-term outcome of laparoscopic repair of
paraesophageal hernia. Surg Endosc. 2002;16(5):
745–9.
17. Iqbal A, Kakarlapudi GV, Awad ZT, Haynatzki G, Turaga
KK, Karu A, Fritz K, Haider M, Mittal SK, Filipi CJ.Assessment of diaphragmatic stressors as risk factors for
symptomatic failure of laparoscopic nissen fundoplication. J Gastrointest Surg. 2006;10(1):12–21.
Is What I am Doing Every Day Evidence Based?
18. Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Stefanidis
D, Fanelli RD; SAGES Guidelines Committee. Guidelines for the management of hiatal hernia. Surg
Endosc. 2013;27(12):4409–28.
19. Iqbal A, Kakarlapudi GV, Awad ZT, Haynatzki G, Turaga
KK, Karu A, Fritz K, Haider M, Mittal SK, Filipi CJ.Assessment of diaphragmatic stressors as risk factors for
symptomatic failure of laparoscopic nissen fundoplication. J Gastrointest Surg. 2006;10(1):12–21.
20. Debray C, Poinsard G, Deporte A. Gastric distension
tachycardia syndrome, an occasionally severe complication of operated hiatal hernia. Actual Hepatogastroenterol (Paris). 1965;1:304–12.
21. Mittal SK, Bikhchandani J, Gurney O, Yano F, Lee T. Outcomes after repair of the intrathoracic stomach: objective
follow-up of up to 5 years. Surg Endosc. 2011;25:556–66.
22. Andujar JJ, Papasavas PK, Birdas T, Robke J, Raftopoulos Y, Gagne DJ, Caushaj PF, Landreneau RJ, Keenan
RJ.Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence
and reoperation. Surg Endosc. 2004;18:444–7.
23. Jobe BA, Aye RW, Deveney CW, Domreis JS, Hill
LD.Laparoscopic management of giant type III hiatal
hernia and short esophagus. Objective follow-up at
three years. J Gastrointest Surg. 2002;6:181–8.
24. Chrysos E, Tsiaoussis J, Athanasakis E, Zoras O, Vassilakis JS, Xynos E.Laparoscopic vs open approach for Nissen fundoplication. A comparative study. Surg Endosc.
2002;16:1679–84.
25. Pitcher DE, Curet MJ, Martin DT, Vogt DM, Mason J,
Zucker KA. Successful laparoscopic repair of paraesophageal hernia. Arch Surg. 1995;130:590–6.
26. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic
reduction, crural repair, and fundoplication of large
hiatal hernia. Am J Surg. 1992;163:425–30.
27. Congreve DP. Laparoscopic paraesophageal hernia
repair. J Laparoendosc Surg. 1992;2:45–8.
28. Behrns KE, Schlinkert RT. Laparoscopic management
of paraesophageal hernia: early results. J Laparoendosc Surg. 1996;6:311–7.
29. Perdikis G, Hinder RA, Filipi CJ, Walenz T, McBride PJ,
Smith SL, Katada N, Klingler PJ.Laparoscopic paraesophageal hernia repair. Arch Surg. 1997;132:586–9.
30. Edye MB, Canin-Endres J, Gattorno F, Salky BA.Durability of laparoscopic repair of paraesophageal hernia.
Ann Surg. 1998;228:528–35.
31. Schauer PR, Ikramuddin S, McLaughlin RH, Graham TO,
Slivka A, Lee KK, Schraut WH, Luketich JD.Comparison
of laparoscopic versus open repair of paraesophageal
hernia. Am J Surg. 1998;176:659–65.
32. Oelschlager BK, Pellegrini CA.Paraesophageal hernias:
open, laparoscopic, or thoracic repair? Chest Surg Clin
N Am. 2001;11:589–603.
33. Rosen M, Ponsky J.Laparoscopic repair of giant paraesophageal hernias: an update for internists. Cleve
Clin J Med. 2003;70:511–4.
34. Low DE, Unger T.Open repair of paraesophageal hernia: reassessment of subjective and objective outcomes. Ann Thorac Surg. 2005;80:287–94.
35. Diez Tabernilla M, Ruiz-Tovar J, Grajal Marino R, Calero
Garcia P, Pina Hernandez JD, Chames Vaisman A,
Morales Castineiras V, Sanjuanbenito Dehesa A, Martinez Molina E, Fresneda MV.Paraesophageal hiatal hernia. Open vs laparoscopic surgery. Rev Esp Enferm Dig.
2009;101:706–11.
36. Zehetner J, Demeester SR, Ayazi S, Kilday P, Augustin F,
Hagen JA, Lipham JC, Sohn HJ, Demeester TR.Laparoscopic versus open repair of paraesophageal hernia:
the second decade. J Am Coll Surg. 2011;212:813–20.
40
Complex Hiatal Hernias
DirkWeyhe andPradeepChowbey
41.1 Upside-Down Stomach – 422
41.1.1 Hiatial Hernia Classication – 422
41.1.2 Mesh Augmentation – 422
41.1.3 How IDo It – 426
41.1.4 Summary – 428
41.2 Short Esophagus – 428
41.2.1 Introduction – 428
41.2.2 Classication – 429
41.2.3 Treatment Options Include – 429
41.2.4 Esophageal Lengthening Procedures – 429
41.2.5 Conclusion – 429
421
41
References – 430
© 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_41
422
D. Weyhe and P. Chowbey
41
41.1 Upside-Down Stomach
DirkWeyhe
41.1.1
Hiatial Hernia Classication
Hiatial hernia oen develops due to a combination of insucient hiatial xation of the cardia
region and concurrent intra-abdominal pressure,
which mainly arise due to age and/or obesity [1].
e amount of dislocated tissue is used to classify
hiatial hernia:
5 Type I: axial hernia
5 Type II: paraesophageal hernia
5 Type III: combination of I and II
5 Type IV: large hiatial hernia with additional
abdominal organs dislocated into the thorax
Classication of hiatial hernia: Type I, axial
hernia; Type II, paraesophageal hernia; Type
III, combination of I and II; and Type IV, large
hiatial hernia with abdominal organs (besides
the stomach) dislocated into the thorax
For the most common, reversible axial hernia
(Type I), the cardia region is dislocated in longitudinal direction above the hiatus esophagi. Most
Type I hernias (80–90%) are incidental ndings in
the context of gastroscopies. e paraesophageal
hernia (Type II) is characterized by the dislocation of parts of the stomach following larger hiatial defects and a subphrenic cardia (i.e., inloco
typico). e subphrenic cardia is by denition the
main distinguishing feature of a Type II hiatial
hernia and results in a more or less completely
thorarcal antrum region. e upside-down stomach may occur as a maximal variation even in a
Type II hiatial hernia. A Type III hernia is characterized by a mix between axial and paraesophageal hernia in addition to an intrathoracic,
dislocated cardia. Type IV hiatial hernias are very
rare, and they are dened by the dislocation of
abdominal organs like the small intestine, colon,
pancreas, and spleen, in addition to the stomach.
Patients with dislocated abdominal organs may
be asymptomatic for a long time, until they present
with exertional dyspnea or pulmonary brosis
with chronic recurrent silent aspiration, and differential diagnosis then reveals well- progressed
clinical ndings. Dysphagia, regurgitation, postprandial cardiovascular disorders, arrhythmia, and
anemia are typical symptoms for large hiatial hernia, whereas reux is an infrequently reported
symptom.
e actual prevalence of so-called “complex”
or “large” hiatial hernia is unknown. Also, there
are no clearly dened criteria for “medium-” or
“large-”sized hernia, and therefore dierentiation
according to size is inconsistent. Disregarding the
Type I–IV classication, comparison between
studies or research questions is therefore nearly
impossible. In addition, there are ongoing discussions concerning details of surgical procedure.
For example, it still remains unclear whether
resection of the hernial sac or simple gastropexy is
a valid alternative for simultaneously performed
antireux procedure (360°/270° Fundoplication),
which is a common standard nowadays. Another
central, currently unanswered question concerns
the practice of mesh augmentation for “large” hiatal hernia.
41.1.2 Mesh Augmentation
Indication forMesh Augmentation
For abdominal wall or inguinal hernia, mesh augmentation is a standard surgical procedure and an
integral part of international guidelines with
high-level evidence, both for conventional and for
laparoendoscopic techniques [2, 3]. By contrast,
guidelines are very cautious concerning recommendations for mesh implants at the hiatus
esophagi [4]. According to SAGES, missing longterm evidence, as well as the potential risk of local
chronic foreign body reaction, and heterogeneous
study results with regard to the implant materials
do not allow for a conclusive recommendation.
Guidelines are very cautious concerning
recommendations for mesh implants at the
hiatus esophagi due to missing long-term
evidence and potential risks.
However, according to Rathore et al. [5],
recurrence rates of 25% and above may be
expected aer using mere suture technique, not
taking individual surgical learning curves into
account. By contrast, aer initial surgery with hiatal augmentation using alloplastic or biological
Complex Hiatal Hernias
. Fig.41.1 Pascal’s
principle; hydrostatic
pressure evenly spreads in
all directions at each point
of a uid. Therefore, with a
small force F1 a large force
F2 might be exerted
423
F = Force
F
1
A = Area
Stamps
F
2
41
A
1
materials, revisions needed due to recurrence are
oen associated with high morbidity, including
the potential need for an esophagectomy [6].
Individual surgeons might reach dierent decisions with regard to the risk-benet analysis
resulting from careful consideration of these
arguments. is may explain the questionnaire
result of Puke etal. [7], according to which more
than 50% of all interrogated surgeons state that
they rarely or never use mesh augmentation in the
surgical treatment of hiatial hernia.
Biomechanical Principles
ofMesh Augmentation
In comparison to solely using suture techniques,
mesh augmentation at the hiatus esophagi reduces
the risk of recurrence [8, 9]. Since the rst hiatal
mesh augmentation published by Kuster and Gilroy
[10], a plethora of modied techniques for mesh
augmentation aer hiatial hernia were described.
Some surgeons only implement a partial augmentation of the dorsal crura, whereas other surgeons
perform a circular augmentation of the hiatus
esophagi. However, partial, strip- shaped, or
U-shaped augmentation of the defect strongly disagrees with main principles of inguinal or incisional
hernia surgery implemented in recent years [3, 11]
and with the laws of physics in general. Because of
Pascal’s principle of uniform pressure distribution
. Fig.41.1), a mesh overlap at the defect location
(
of at least 3–5cm is needed for a complete and sustainable coverage of the defect (. Fig. 41.2; [12,
13]). erefore, all techniques, which use noncir-
cular augmentation, and/or augmentation, which
does not completely cover the defect with sucient
overlap, should not be implemented.
A
2
Because of Pascal’s principle of uniform
pressure distribution, a mesh overlap at the
defect location of at least 3–5cm using circular
augmentation is needed for a complete and
sustainable coverage of the defect.
In keeping with the principle of an abdomen
with abdominal compartmentalization and considering uniform pressure distribution throughout the whole abdomen (container principle), the
hiatial hernia may be regarded as an abdominal
wall hernia in a broader sense. Consistently, all
theoretical considerations concerning biomechanical rules and principles should be taken into
account as well, even if the practical realization
(e.g., overlap) of those fundamental biomechanical principles at the region of the hiatus esophagi
is somewhat limited. However, they should be
adhered to as closely as possible.
Since recurrence rates increase with increasing
size of the hernia orice [14], and in accordance
with the aforementioned needed overlap, it seems
appropriate to determine the size of the hernia and
to tailor the surgical technique accordingly. Based
on the studies by Granderath and Pointner (e.g.,
Granderath [15]; Granderath et al. [16]), the hiatial surface area (HSA) can be determined by measuring the diaphragmatic side and crural
commissure of the hernia orice intraoperatively
(. Fig. 41.3) and by then plotting the measurements in an appropriate coordinate system
(. Fig.41.4). A hiatial hernia with a HSA>5cm2
may be classied as “large,” and mesh augmentation is recommended. As mentioned above, the
424
D. Weyhe and P. Chowbey
. Fig.41.2 Schematic
mesh augmentation.
Considering Pascal’s
principle, overlap of the
mesh at the hiatus
esophagi should be 3–5cm
. Fig.41.3 Measuring
the size of the hernial
orice
Diaphragm
Hiatial opening
Esophagus
Esophageal passage
perpendicular to the esophagus
Mesh surface
41
crural commissure
coverage of the defect with the mesh should be circular (. Fig.41.5). In addition with a large enough
overlap, the intra-abdominal pressure may then be
distributed across a larger area of tissue [17].
Hiatal hernia with a HSA>5cm2 may be
classied as “large,” and circular mesh
augmentation with at least 3–5cm overlap is
recommended.
diaphragmatic side
Choices ofMesh
With regard to biocompatibility of synthetic
implants, the same minimum requirements apply
at the hiatus esophagi as for all implants used intraabdominally. Lately, the pore size of synthetic
meshes, and not implant weight, was identied to
be the best predictor for optimal mesh integration.
Current guidelines therefore recommend monolament polymers with a pore size of at least 1.0–
1.5 mm. e tensile strength (including tearing
length of the diaphragmatic commissure [cm]
Complex Hiatal Hernias
. Fig.41.4 Determining
the size of the HSA: the
length of the crural
commissure is entered on
the horizontal axis and the
length of the diaphragmatic commissure is
entered on the vertical line.
If the resulting data point is
above the blue line, HSA is
>5cm2, and indication for
mesh augmentation is met
7,5
7
6,5
6
5,5
5
4,5
4
3,5
3
2,5
2
1,5
1
0,5
0
1
1,2 1,4 1,6 1,8 2 2,2
HSA < 5 cm
No mesh indication
HSA > 5 cm
mesh indication
2
;
2,4 2,6 2,8 3 3,2
length of the crural commissure [cm]
425
2
;
3,4 3,6 3,8 4
41
. Fig.41.5 das MRI-visible mesh (left) and its placement centrally around the hiatus esophagi
force) should be >16N/cm2 [18]. In addition, in
the last decade, there has been a paradigm shi
with regard to the denition of biocompatibility.
e initially favored approach of focusing on bionic
material changed into one of maximal implant
integration, which adapts to the desired function
without local or systemic adverse eects [19].
Adhering to the latter denition, currently, no safe
recommendation can be made regarding potential
complications of synthetic meshes or biological
membranes.
Currently, no safe recommendation can be
made regarding the use of synthetic meshes
versus biological membranes.
Short-term results show no dierence between
biological and synthetic implants [20, 21], whereas
in the long term, recurrence rates seem to be
markedly higher for biological implants [4, 22–
24]. e heterogeneity of studies, especially with
regard to missing denition of recurrence (e.g.,
asymptomatic vs. symptomatic), dierences in
follow-up duration, and a plethora of technical
modications, limits the validity of meta- analyses,
such that surgeons still can choose the mesh at
their own discretion [25].
Potential Complications
ofMesh Augmentation
As described in small case series, uncoated polymers built from polypropylene or polyester are
associated with higher chronic foreign body reactions and with a higher risk of hollow organ erosion
or intestinal stula [26–28]. Coated polymers seem
to reduce these risks (e.g., Köckerling and SchugPass [29]). Meshes built from combinations of
PTFE and polypropylene may not be integrated
fully in the surrounding tissue, thus increasing the
426
D. Weyhe and P. Chowbey
. Fig.41.6 Mesh
deformation for an applied
force of 50Nm is a
predictor for mesh
shrinkage
41
risk of mesh shrinkage [30, 31]. Use of biological
membranes may result in higher recurrence rates
and dysphagia due to brosis.
Overall, the material-related potential for
complications seems to be overestimated for polypropylene meshes, if the number of published
complications is related to the amount of polypropylene implants used in hiatial surgery
(18/2181 ≈ 0.8%). Indeed, complication rates
seem to be the lowest for meshes made from polypropylene and for completely absorbable polyglactin meshes [32].
41.1.3 How IDo It
Choice ofMesh
Especially in circular augmentation of a hiatial
defect, mesh shrinkage may have enormous consequences, since shrinkage is likely associated with
postoperative dysphagia. erefore, structural stability is of main importance, since high structural
stability may reduce the potential for shrinkage in
synthetic meshes. For instance, in vivo animal
studies showed that the amount of elongation and
deformation (. Fig.41.6) occurring for forces of
50Nm is predictive of shrinkage [33].
To avoid shrinkage with subsequent dysphagia, meshes with high structural stability
should be used.
erefore, in our clinic, we use an MRI- visible,
synthetic mesh with high structural stability [34].
us we are able to observe both, shrinkage due to
strain and/or incomplete healing processes and
development of recurring hernia in the long term
(. Fig.41.7). e rational behind the usage of the
MRI-visible mesh is the consistent implementation of the circular overlap principle described
above. e hernia orice (in terms of HSA) is
measured and is covered by the mesh by at least
2–3cm in all directions. To prevent dysphagia due
to stenosis, shrinkage is taken into account as
well. Only absorbable tackers are used. Eciency
of the xation is validated by directly postoperative and long-term MRI.
Complex Hiatal Hernias
. Fig.41.7 Perioperative
MRI and 1-year follow-up to
visually control the healing
process and potential mesh
shrinkage
427
41
MRI-visible implants allow for visual control
of the mesh position, even in the long term.
Surgical Steps inDetail
Positioning andPreparations
Surgery is performed in beach chair position.
Aer application of the trocars, the le part of the
liver is retracted with a fan. e hiatial orice is
prepared, and all dislocated tissue is repositioned
into the abdomen. e pars accida is severed,
and the diaphragmatic commissure of the hiatial
orice is prepared clockwise, followed by the
preparation of the intrathoracic hernia sac.
Hernial sac preparation is best done mostly
blunt with a compact sponge.
e intrathoracic part of the esophagus is mobilized over at least 5cm. Depending on the amount
of tissue, the hernial sac is resected and removed to
allow for easy suture of the fundic wrap.
! After preparation, the cardia should be
positioned intra-abdominally without
traction. Otherwise further intrathoracic
mobilization of the esophagus might occur
(cave circulatory disorder).
Hiatal Surface Area (HSA)
To assess the need for mesh augmentation, the
diaphragmatic side and crural commissure of the
hernia orice are measured intraoperatively. A
surgical nurse copies the values into the aforementioned graph. A HSA>5cm2 is indicative of
mesh augmentation.
For easy measurement, take a 6–8cm suture
and measure both the diaphragmatic side and
crural commissure. The rst forceps spans the
suture, and the second marks the length of
the commissure. The length of the marked
part of the suture is measured extracorporeal.
Hiatus Reconstruction
Dorsal hiatoplasty is performed by three intracorporeal simple interrupted stiches using polyester sutures. Depending on the anatomy and the
size of the hernial orice, an additional ventral
suture might be necessary. For HSA>5cm
indication for mesh augmentation is met. We use
a MRI-visible PVDF polymer (DynaMesh® visible; size: 15 × 12 cm). e slit mesh is pulled
underneath the esophagus from le to right and
is placed such that the slit comes to rest at the
upper le quadrant. In its resting position,
the central mesh opening should not touch the
2
, the