Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature. Surg Endosc. 2013;27:3998-4008. [PMID: 23793804 DOI: 10.1007/s00464-013-3036-y]

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial

Background

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair.

Patients and methods

All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh.

Results

The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation.

Trial Registration

ClinicalTrials.gov, identification number NCT04179578.

Non-destructive processing of silver containing glass ceramic antibacterial coating on polymeric surgical mesh surfaces

Surgical meshes composed of bioinert polymers such as polypropylene are widely used in millions of hernia repair procedures to prevent the recurrence of organ protrusion from the damaged abdominal wall. However, post-operative mesh infection remains a significant complication, elevating hernia recurrence risks from 3.6% to 10%, depending on the procedure type. While attempts have been made to mitigate these infection-related complications by using antibiotic coatings, the rise in antibiotic-resistant bacterial strains threatens their effectiveness. Bioactive glass-ceramics featuring noble metals, notably silver nanoparticles (AgNPs), have recently gained traction for their wide antibacterial properties and biocompatibility. Yet, conventional methods of synthesizing and coating of such materials often require high temperatures, thus making them impractical to be implemented on temperature-sensitive polymeric substrates. To circumvent this challenge, a unique approach has been explored to deposit these functional compounds onto temperature-sensitive polypropylene mesh (PP-M) surfaces. This approach is based on the recent advancements in cold atmospheric plasma (CAP) assisted deposition of SiO2 thin films and laser surface treatment (LST), enabling the selective heating and formation of functional glass-ceramic compounds under atmospheric conditions. A systematic study was conducted to identify optimal LST conditions that resulted in the effective formation of a bioactive glass-ceramic structure without significantly altering the chemical and mechanical properties of the underlying PP-M (less than 1% change compared to the original properties). The developed coating with optimized processing conditions demonstrated high biocompatibility and persistent antibacterial properties (>7 days) against both Gram-positive and Gram-negative bacteria. The developed process is expected to provide a new stepping stone towards depositing a wide range of functional bioceramic coatings onto different implant surfaces, thereby decreasing their risk of infection and associated complications.

Complications, caused by application of the net implants in the hiatal hernias plasty

Objective. Studying of complications, connected with application of the net implants in patients with large hiatal hernias. Materials and methods. Retrospective investigation was conducted with objective to study complications, connected with application of the net implants in patients with large hiatal hernias, operated in the clinic during period from 2008 to 2018 yr. Of 1168 patients operated on and suffering gastro-esophageal reflux disease as well as hiatal hernias, 817 have had large hernias. In 353 patients with large hernias for strengthening of cruroraphy sutures the net implants were applied. There were used low-weighted implant-net Ultrapro, the composite net Parietex, self-fixating surgical net ProGrip, absorbable net Vicryl, polytetrafluoroethylene net with nitinol carcass, biological net Bio-A. All the patients symptoms were registered, and the quality of life studied. Results. Complications, caused by the net implants impact, were revealed in 17 (1.5%) patients. In all 17 patients the esophageal structuring have occurred due to pronounced cicatrization in region of the net implant installation. In 6 patients dysphagia due to the net ingrowth into esophageal tissue was observed, and in 2 – chronic inflammatory process in place of the net installation. One patient have had small esophageal perforation with restricted mediastinitis. In 3 patients, in whom the polytetrafluoroethylene nets were installed, their migration into esophageal lumen was revealed. Reoperations were done in all 17 patients. In 7 patients the net was removed completely. In 1 patient the net was removed and mediastinum drained. In 3 patients, in whom polytetrafluoroethylene nets have migrated into esophageal lumen, they were removed endoscopically with further installation of special stents. Results of reoperations were estimated as good in 15 patients. In 2 patients after reoperations dysphagia was observed, which needed a second time balloon dilatation and installation of stent in 1 of them. Conclusion. Nonabsorbable nets ought to be applied with high technical accuracy, it is necessary to prevent their contact with the esophagus. Application of the polytetrafluoroethylene nets with nitinol carcass for plasty of large hiatal hernias must be forbidden.

Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

A Systematic Review Examining the Experimental Methodology Behind In Vivo Testing of Hiatus Hernia and Diaphragmatic Hernia Mesh

INTRODUCTION

Mesh implants are regularly used to help repair both hiatus hernias (HH) and diaphragmatic hernias (DH). In vivo studies are used to test not only mesh safety, but increasingly comparative efficacy. Our work examines the field of in vivo mesh testing for HH and DH models to establish current practices and standards.

METHOD

This systematic review was registered with PROSPERO. Medline and Embase databases were searched for relevant in vivo studies. Forty-four articles were identified and underwent abstract review, where 22 were excluded. Four further studies were excluded after full-text review-leaving 18 to undergo data extraction.

RESULTS

Of 18 studies identified, 9 used an in vivo HH model and 9 a DH model. Five studies undertook mechanical testing on tissue samples-all uniaxial in nature. Testing strip widths ranged from 1-20 mm (median 3 mm). Testing speeds varied from 1.5-60 mm/minute. Upon histology, the most commonly assessed structural and cellular factors were neovascularisation and macrophages respectively (n = 9 each). Structural analysis was mostly qualitative, where cellular analysis was equally likely to be quantitative. Eleven studies assessed adhesion formation, of which 8 used one of four scoring systems. Eight studies measured mesh shrinkage.

DISCUSSION

In vivo studies assessing mesh for HH and DH repair are uncommon. Within this relatively young field, we encourage surgical and materials testing institutions to discuss its standardisation.

Repair of Large Hiatal Hernias With the Use of Mesh and Autologous Platelet-Rich Plasma

BACKGROUND

According to recent studies, large hiatal hernias (HH) can be associated with a lower content of type-I and type-III collagen in the phrenoesophageal ligament (POL). We therefore hypothesize that the use of a mesh implant with autologous platelet-rich plasma (PRP) for repair of large HH would have a positive effect on long-term outcome.The purpose of our study was to determine the level of type-I and type-III collagens in the POL of patients with large HH with the aim of improving the technique of HH repair.

MATERIALS AND METHODS

During the first phase of the study, the collagen content within the POL was assessed in 18 patients with HH and 14 cadaveric specimens without HH. During the second phase, 54 patients with large HH (defined as 10 to 20 cm2), that required surgery were recruited. Laparoscopic repair involved use of a nonabsorbable self-fixating ProGrip mesh infiltrated with 2 to 4 mL of autologous PRP was used for reinforcement of crural repair. Results were assessed using endoscopy, barium swallow, 24-hour impedance-pH monitoring and a quality of life gastroesophageal reflux disease-health related quality of life questionnaire.

RESULTS

The content of collagen within POL in patients with HH was significantly lower than in the cadaveric specimens without HH. Of the 54 patients undergoing HH repair, all procedures were performed laparoscopically and there were no mortalities in this group. At 48 months, only 2 HH recurrences (3.7%) were detected. During this period, the mean gastroesophageal reflux disease-health related quality of life score decreased from 15.7±5.5 to 5.9±0.6 (P<0.05).

CONCLUSION

Our study has shown that the collagen content is reduced in patients with large HH; thus, it is advisable to use mesh for HH repair in such patients. Use of mesh infiltrated in PRP is safe and can have positive impact on results of HH repair.

Cumulative summation analysis of learning curve for robotic-assisted hiatal hernia repairs

BACKGROUND

Robotic-assisted laparoscopic surgery (RALS) is evolving as an important surgical approach in the field of general surgery. We aimed to evaluate the learning curve for RALS procedures involving repair of hiatal hernias.

METHODS

A series of robotic-assisted hiatal hernia (HH) repairs were performed between 2013 and 2017 by a surgeon at a single institution. Data were entered into a retrospective database. Patient demographics and intraoperative parameters including console time (CT), surgery time (ST), and total operative time (OT) were examined and abstracted for learning curve analysis using the cumulative sum (CUSUM) method. Assessment of perioperative and post-operative outcomes were calculated using descriptive statistics.

RESULTS

The average age of the patients was 57.4 years, average BMI was 29.9 kg/m², median American Society of Anesthesiologists (ASA) classification was 2, and average Charlson Comorbidity Index (CCI) score was 2.8. The series had a mean CT of 132.6 min, mean ST of 145.1 min, and mean OT of 197.4 min. The CUSUM learning curve for CT was best approximated as a third-order polynomial consisting of three unique phases: the initial training phase (case 1-40), the improvement phase (case 41-85), and the mastery phase (case 86 onwards). There was no significant difference in perioperative complications between the phases. Short-term clinical outcomes were comparable with national standards and did not correlate significantly with operative experience.

CONCLUSIONS

The three phases identified with CUSUM analysis represented characteristic stages of the learning curve for robotic hiatal hernia procedures. Our data suggest the training phase is achieved after 40 cases and a high level of mastery is achieved after approximately 85 cases. Thus, the CUSUM method serves as a useful tool for objectively evaluating practical skills for surgeons and can ultimately help establish milestones that assess surgical competency during robotic surgery training.

Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): a prospective comparative single center study

BACKGROUND

Complete upside-down stomach (cUDS) hernias are a subgroup of large hiatal hernias characterized by high risk of life-threatening complications and technically challenging surgical repair including complex mediastinal dissection. In a prospective, comparative clinical study, we evaluated intra- and postoperative outcomes, quality of life and symptomatic recurrence rates in patients with cUDS undergoing robot-assisted, as compared to standard laparoscopic repair (the RATHER-study).

METHODS

All patients with cUDS herniation requiring elective surgery in our institution between July 2015 and June 2019 were evaluated. Patients undergoing primary open surgery or additional associated procedures were not considered. Primary endpoints were intra- and postoperative complications, 30-day morbidity, and mortality. During the 8-53 months follow-up period, patients were contacted by telephone to assess symptoms associated to recurrence, whereas quality of life was evaluated utilizing the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire.

RESULTS

A total of 55 patients were included. 36 operations were performed with robot-assisted (Rob-G), and 19 with standard laparoscopic (Lap-G) technique. Patients characteristics were similar in both groups. Median operation time was 232 min. (IQR: 145-420) in robot-assisted vs. 163 min. (IQR:112-280) in laparoscopic surgery (p < 0.001). Intraoperative complications occurred in 5/36 (12.5%) cases in the Rob-G group and in 5/19 (26%) cases in the Lap-G group (p = 0.28). No conversion was necessary in either group. Minor postoperative complications occurred in 13/36 (36%) Rob-G patients and 4/19 (21%) Lap-G patients (p = 0.36). Mortality or major complications did not occur in either group. Two asymptomatic recurrences were observed in the Rob-G group only. No patient required revision surgery. Finally, all patients expressed satisfaction for treatment outcome, as indicated by similar GERD-HRQL scores.

CONCLUSION

While robot-assisted surgery provides additional precision, enhanced visualization, and greater feasibility in cUDS hiatal hernia repair, its clinical outcome is at least equal to that obtained by standard laparoscopic surgery.

What Is the Reality of Hiatal Hernia Management?-A Registry Analysis

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions.

Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010–2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010–2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared.

Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of “other techniques” at 20.9%. For the paraesophageal hiatal hernias (types II–IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and “other techniques” of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates.

Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the “classic” Nissen and Toupet fundoplication surgical techniques.

Mesh-related complications in paraoesophageal repair: a systematic review

BACKGROUND

Paraoesophageal hernias (PEH) have a high recurrence rate, prompting surgeons to consider the use of mesh reinforcement of the hiatus. The risks and benefits of mesh augmentation in PEH repair are debated. Mesh-related complications including migration and erosion are considered in this publication.

DESIGN

A systematic literature review of articles published between 1970 and 2019 in Medline, OVID, Embase, and Springer database was conducted, identifying case reports, case series and observational studies of PEH repair reporting mesh-related complications.

RESULTS

Thirty-five case reports/series of 74 patients and 20 observational studies reporting 75 of 4200 patients with mesh complications have been included. The incidence of mesh-related erosions in this study is 0.035%. PTFE, ePTFE, composite and synthetic meshes were frequently associated with mesh erosion requiring intervention. Complete erosions are often managed endoscopically while partial erosions may require surgery and resection of the oesophagus and/or stomach.

CONCLUSIONS

Mesh-related complication is rare with dysphagia a common presenting feature. Mesh erosion is associated with synthetic mesh more frequently in the reported literature. A mesh registry with long-term longitudinal data would help in understanding the true incidence of mesh-related complications.

A Collective Review of Gore Bio-A Absorbable Synthetic Mesh in Cruroplasty Reinforcement

Background: Laparoscopic repair of hiatal hernia (HH) is associated with a considerable failure rate. Compared to suture repair alone, mesh-reinforced cruroplasty may be associated with fewer short-term recurrences, yet its use remains controversial. The aim of this study was to analyze the current literature assessing the use of Bio-A absorbable synthetic mesh in the reinforcement of primary crural closure after laparoscopic HH repair. Methods: A systematic review of primary literature in the MEDLINE and PubMed databases was conducted. We searched for investigations reporting patient outcomes in laparoscopic HH repair with onlay Gore Bio-A tissue reinforcement (W. L. Gore & Associates, Inc.) published between January 2008 and December 2019. The primary outcome was anatomical recurrence rate. Secondary outcomes were complication rate, symptomatic outcomes, and mortality. Results: Eight studies met inclusion criteria. There were two prospective and six retrospective cohort studies. In the included studies, laparoscopic HH repair was performed with Bio-A absorbable synthetic mesh in 734 patients. The anatomical recurrence data were extracted across all studies, and an objective recurrence was identified in 21/280 (7.5%) patients. There was only 1 (0.17%) mesh-related complication in the included studies. Conclusions: The use of Bio-A absorbable synthetic mesh in the repair of HHs may be promising, as it offers low rates of anatomical recurrence and mesh-related complications, but more data are still necessary to validate these findings. This collective review of literature is a basis for future randomized controlled trials to identify the most effective and safe mesh in the long term.

Clinical and Quality of Life Assessment of Patients Undergoing Laparoscopic Hiatal Hernia Repair

Hiatal hernia repair (HHR) and fundoplication are similarly performed among all hiatal hernia types with similar techniques. This study evaluates the effect of HHR using a standardized technique for cruroplasty with a reinforcing polyglycolic acid and trimethylene carbonate mesh (PGA/TMC) on patient symptoms and outcomes. A retrospective review of patient perioperative characteristics and postoperative outcomes was conducted for cases of laparoscopic hiatal hernia repair (LHHR) using a PGA/TMC mesh performed over 21 months. Gastroesophageal reflux disease symptom questionnaire responses were compared between preoperative and three postoperative time points. Ninety-six patients underwent LHHR with a PGA/TMC mesh. Post-operatively, the number of overall symptoms reported by patients decreased across all postoperative periods ( P < 0.001). Patients reported a significant reduction in antacid use long term ( P < 0.001). Laryngeal and regurgitation symptoms decreased at all time points ( P < 0.05). There was no difference in dysphagia preoperatively and postoperatively at any time point. Individuals undergoing HHR with PGA/TMC mesh experienced improved regurgitation and laryngeal symptoms, and decreased use of antacid medication.

Paraesophageal Hernia: To Mesh or Not to Mesh? The Controversy Continues

Introduction: Paraesophageal hernias represent 5%-10% of all primary hiatal hernias and are becoming increasingly more common with the aging of the population. Surgical treatment includes closure of the wide hiatal gap. Achieving tension-free closure is difficult, and several studies have reported lower recurrence rates with the use of mesh reinforcement. The use of this technique, however, is controversial. Objective and Materials and Methods: Narrative revision of the literature revising: (1) evidence-based surgery and clinical studies, (2) what the experts say (Delphi), (3) complications of mesh, and (4) long-term results of laparoscopic treatment impact on the quality of life. Results: Consensus about the type of mesh continues to be elusive, and we clearly need a higher level of evidence to address the controversy. Conclusion: Mesh reinforcement can effectively reduce the hernia recurrence rate. Mesh-associated complications are few, but because they are serious, most experts recommend mesh use only in specific circumstances, particularly those in relation to the size of the hiatal defect and the quality of the crura.

Laparoscopic repair of hiatal hernia

Background

Laparoscopic hiatal hernia repair is a complex surgery typically performed by general abdominal surgeons because it typically involves an abdominal approach. Here, we report our experiences on laparoscopic repair of hiatal hernia as thoracic surgeons.

Methods

Based on our experience of minimally invasive esophageal surgery (MIES) for esophageal cancer, we began performing laparoscopic repair of hiatal hernia in 2009. We analyzed the surgery-related data and postoperative outcomes of 18 consecutive patients we operated on from 2009 to 2017.

Results

There were 1 male and 17 female patients with a median age of 73 years (range, 37-81 years). Ten of 14 symptomatic patients experienced reflux symptoms, such as heartburn. Four patients had a history of prior abdominal surgery. Hiatal hernia types I, II, III, and IV were observed in 3, 9, 5, and 1 patients, respectively. Two (11.1%) laparoscopic procedures required conversion. Modified Collis gastroplasty was used as an esophageal lengthening procedure in 5 patients (27.8%). Mean operation time was 213.8±70.1 minutes and mean hospital stay was 6.2±1.5 days. There were no postoperative complications. At the last follow-up, 15 patients (83.3%) were asymptomatic; however, 3 (16.7%) complained of reflux or dysphagia. Recurrent hiatal hernia was detected on an esophagogram in only 1 patient at 3.5 years after laparoscopic surgery.

Conclusions

Laparoscopic repair of hiatal hernia is a feasible technique with a satisfactory surgical outcome. Importantly, it can be performed by thoracic surgeons who are experienced in the laparoscopic approach.

Minimally invasive surgery for large hiatal hernia

The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.

The first year is the hardest: a comparison of early versus late experience after the introduction of robotic hiatal hernia repair

While the majority of the literature written concerning minimally invasive hiatal hernia repair involves laparoscopy, little has been written concerning the transition to a robotic technique. We present our experience, with a transparent analysis of data, with regard to the introduction of robotic paraesophageal hernia (PEH) repair by an experienced laparoscopic surgeon. We reviewed our first 30 consecutive patients who underwent robotic PEH over a 2-year period after the introduction of robotic surgery at our institution. Patients were divided into two groups: the early experience group (procedures performed within the first year of introduction of robotic technique, n = 13) and a late experience group (procedures performed in the second year, n = 17). All procedures were performed by a single experienced foregut surgeon. The mean operative time for the early group was significantly greater than for the late group, 184 min versus 142 min, respectively (p < 0.01). Four patients in the early group required conversion to open, while zero patients in the late group required conversion (p = 0.03). Patient demographics and complications did not differ significantly between the two patient populations. The early robotic hiatal hernia repair experience can be more difficult than expected, even in the hands of an experienced laparoscopic team. We identify several areas of improvement including patient positioning, operating room team training, and technical experience. This data can help other surgeons prepare for the transition to robotic foregut surgery.

Application of shaft method assisted biological mesh in laparoscopic inguinal hernia repair

To compare the feasibility and advantage of traditional tiling method and shaft method to place biological mesh following laparoscopic repair of inguinal hernia.Sixty cases from January 2013 to January 2014 treated with laparoscopic inguinal hernia neoplasty with biological patches were included. All the cases were randomly divided into control group and observation group. Observation group was treated with shaft method to place biological mesh, while control group was treated with traditional tiling method. The length of the operation, hospital fees, and rate of occurrence of surgical complications were compared.All 60 cases were successfully treated with laparoscope inguinal hernia repair. None were converted to open operations. Total operation times for the observation group and control group were 54 ± 4.5 and 71 ± 7.2 minutes, respectively (P < .05). The hospital fees of the observation group and control group were 21,280 ± 365 RenMinBi Yuan (RMB) and 24,280 ± 428 RMB, respectively (P < .05). The rates of occurrence of surgical complications were 3.33% (1/30) and 16.7% (5/30), respectively (P < .05).The shaft method can be applied in laparoscopic inguinal hernia repair with biological mesh. Compared with the traditional method, the shaft method has apparent advantages, fewer complications during and after the operation.

Mesh implants for hernia repair: an update

INTRODUCTION

Today the use of textile meshes has become a standard for the treatment of abdominal wall hernias and for the reinforcement of any tissue repair as the strength of the implant decreases the recurrence rates. With increasing use, side effects of the textile implants became apparent, as well.

AREAS COVERED

Based on publications in Medline over the past decade, general and specific benefits, as well as risks, are discussed with the challenge to define individual risk-benefit ratios. For meshes, certain high-risk or low-risk conditions can be defined. In an attempt to eliminate mesh-related risks, quality control for medical devices has meanwhile been revised. In both the USA and the EU post-market surveillance studies are required to keep medical devices approved.

EXPERT COMMENTARY

The impact of material on the complication rate will vary depending on the patient's co-morbidity or the risks of the procedure. Even the best material can end up with disappointing results in case of poor healing or poor surgery. On the other hand, when using high-risk devices, most of the complications after excellent surgery with excellent indication can be supposed to be mesh-related. Thus, the use of low-risk devices is recommended even though its advantage may not be demonstrable in clinical studies.

Biologic Keyhole Mesh in Hiatal Hernia Repair

Background and Objectives

Laparoscopic paraesophageal hernia repair (LPEHR) is the new standard, but the use of mesh is still debated. Biologic mesh has shown great promise, but only the U-shaped onlay has been extensively studied. Postoperative dysphagia has historically been a concern with the use of synthetic keyhole mesh and subsequently slowed its adoption. The purpose of our study was to identify the incidence of postoperative dysphagia in a series of patients who underwent laparoscopic paraesophageal hernia repair with novel placement of keyhole biologic mesh.

Methods

Thirty consecutive patients who underwent hernia repair with primary suture cruroplasty and human acellular dermal matrix keyhole mesh reinforcement were reviewed over a 2-year period. All procedures were performed at a single institution. Postoperative symptoms were retrospectively identified. Any postoperative hernia on imaging was defined as radiographic recurrence.

Results

Of the 30 consecutive patients who underwent hernia repair, 3 (10%) had mild preoperative dysphagia. The number remained unchanged after LPEHR with keyhole mesh. Return of mild reflux symptoms occurred in 6 (20%) patients. Repeat imaging was performed in 11 patients (37%) at an average of 8 months with 2 slight recurrences. All hernias were classified on preoperative imaging as large hiatal hernias. There were no postoperative complications.

Conclusion

Laparoscopic paraesophageal hernia repair with biologic keyhole mesh reinforcement has a low recurrence rate and no increase in postoperative dysphagia. The traditional belief that keyhole mesh has a higher incidence of dysphagia was not evident in this series.

Hiatal hernia involving prolapse of the entire stomach into the mediastinum after distal gastrectomy: a case report

Background

Prolapse of a small part of the proximal stomach through the hiatus into the mediastinum is relatively common. Hiatal hernia involving the postoperative stomach has been reported previously, but the degree of hernia was not so severe, and hiatal hernia involving the prolapse of the entire stomach following gastrectomy into the mediastinum has never been reported. We describe a very rare case of large hiatal hernia involving the entire postoperative stomach.

Case presentation

A 79-year-old man with a history of distal gastrectomy for submucosal benign tumor 40 years ago was referred to our hospital because of dysphagia and weight loss. Computed tomography revealed prolapse of the entire postoperative stomach into the mediastinum, and a radical operation was performed. There was a strong adhesion in the hernial sac of the mediastinum, but only little adhesion due to a previous open surgery in the abdominal cavity was present. After the stomach was pulled into the abdominal cavity, suture cruroplasty and Toupet fundoplication without dissection of the short gastric artery were performed. The patient experienced postoperative paralytic ileus, but the rest of the postoperative course was uneventful and the symptom of dysphagia improved.

Conclusions

We presented a very rare large hiatal hernia involving the entire postoperative stomach. Toupet fundoplication preserving the short gastric artery could be one of the optimal surgeries to prevent postoperative regurgitation of the remnant stomach.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence

BACKGROUND

Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence.

METHODS

We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys.

RESULTS

In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m². The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1  months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups.

CONCLUSIONS

Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

Mesh hiatal reinforcement in laparoscopic Nissen fundoplication for neurologically impaired children is safe and feasible

Fundoplication is a standard treatment for gastroesophageal reflux disease (GERD) in neurologically impaired children. However, it has a high recurrence rate due to wrap herniation and disruption resulting from the failure or enlargement of the esophageal hiatus suture site. In adult patients with GERD, reinforcement of the sutured esophageal hiatus with a mesh significantly reduces the recurrence rate after surgery for esophageal hiatus hernia. In children, there are no big series of fundoplication with mesh reinforcement. Therefore, we confirmed the safety and feasibility of an expanded polytetrafluoroethylene mesh hiatal reinforcement with fundoplication as an additional procedure for neurologically impaired children. Neurologically impaired children (age, ≥5 years) who underwent laparoscopic fundoplication and gastrostomy at our institution between 2011 and 2013 were included in this study. The operative time, bleeding amount, complications, and recurrence were retrospectively evaluated. Thirteen patients were included in this study. The mean age at operation was 147.2 ± 37.8 months, and mean body weight was 18.5 ± 7.9 kg. The complication rate of epilepsy and scoliosis was 100% and 84.6%, respectively. The operative time was 265.1 ± 38.1 minutes, and mean blood loss was 26.5 ± 34.7 mL. There were no peri- or postoperative complications. None of the patients showed recurrent symptoms such as repeated vomiting and aspiration pneumonia during the mean follow-up period of 2.5 ± 0.6 years. The mesh hiatal reinforcement with fundoplication for neurologically impaired children is safe and feasible.

What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II-IV) hiatal hernia repair?

INTRODUCTION

Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures.

MATERIALS AND METHODS

The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair.

RESULTS

Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate.

CONCLUSION

Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.

Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up

BACKGROUND

A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort.

METHODS

Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter.

RESULTS

In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals.

CONCLUSIONS

Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.

A collective review of biological versus synthetic mesh-reinforced cruroplasty during laparoscopic Nissen fundoplication

Background:

Laparoscopic cruroplasty and fundoplication have become the gold standard in the treatment of hiatal hernia and gastro-oesophageal reflux disease (GERD). The use of a mesh-reinforcement of the cruroplasty has been proven effective; although, there is a lack of evidence considering which type of mesh is superior. The aim of this study was to compare recurrence rates after mesh reinforced cruroplasty using biological versus synthetic meshes.

Methods:

We performed a systematic review of all clinical trials published between January 2004 and September 2015 describing the application of a mesh in the hiatal hernia repair during Nissen fundoplication for both GERD and hiatal hernia. The primary outcome was the recurrence rate, and secondary outcomes were complication rate, mortality and symptomatic outcome.

Results:

We included 16 studies and extracted data regarding 1089 mesh operated patients of whom 385 received a biological mesh and 704 a synthetic mesh. The mean follow-up was 53.4 months. The recurrence rate in the synthetic mesh group was 6.8% compared to 16.1% in the biological mesh group (P < 0.05). The complication rate was 5.1% and 4.6% (P = 0.694), respectively, and there were 12 mesh-related complications. No mesh-related mortality was reported.

Conclusion:

Mesh reinforcement of hiatal hernia repair seems safe in the short-term follow-up. The available literature suggests no clear advantage of biological over synthetic meshes. Regarding cost-efficiency and short-term results, the use of synthetic nonabsorbable meshes might be advocated.

Routine use of mesh during hiatal closure is safe with no increase in adverse sequelae

BACKGROUND

Primary laparoscopic hiatal repair with fundoplication is associated with a high recurrence rate. We wanted to evaluate the potential risks posed by routine use of onlay-mesh during hiatal closure, when compared to primary repair.

METHODS

Utilizing single-institutional database, we identified patients who underwent primary laparoscopic hiatal repair from January 2005 through December 2014. Retrospective chart review was performed to determine perioperative morbidity and mortality. Long-term results were assessed by sending out a questionnaire. Results were tabulated and patients were divided into 2 groups: fundoplication with hiatal closure + absorbable or non-absorbable mesh and fundoplication with hiatal closure alone.

RESULTS

A total of 505 patients underwent primary laparoscopic fundoplication. Mesh reinforcement was used in 270 patients (53.5%). There was no significant difference in the 30-day perioperative outcomes between the 2 groups. No clinically apparent erosions were noted and no mesh required removal. Standard questionnaire was sent to 475 patients; 174 (36.6%) patients responded with a median follow-up of 4.29 years. Once again, no difference was noted between the 2 groups in terms of dysphagia, heartburn, long-term antacid use, or patient satisfaction. Of these, 15 patients (16.9%, 15/89) in the 'Mesh' cohort had symptomatic recurrence as compared to 19 patients (22.4%, 19/85) in the 'No Mesh' cohort (p = 0.362). A reoperation was necessary in 6 patients (6.7%) in the 'Mesh' cohort as compared to 3 patients (3.5%) in the 'No Mesh' cohort (p = 0.543).

CONCLUSIONS

Onlay-mesh use in laparoscopic hiatal repair with fundoplication is safe and has similar short and long-term results as primary repair.

Tension-Free Inlay Repair of Large Hiatal Hernias Using Dual-Sided Composite PTFE/ePTFE Meshes in Laparoscopic Surgery for Gastroesophageal Reflux Disease

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) also frequently suffer from concomitant hiatal hernia. It has been described that a preoperative hiatal hernia of ≥3 cm is associated with a more than threefold relative risk for reflux symptom recurrence after fundoplication without mesh reinforcement. In this report, we describe our experience with the implantation of dual-sided composite PTFE/ePTFE meshes in a tension-free fashion during laparoscopic antireflux surgery (LARS).

METHODS

A prospective database containing data of all patients undergoing LARS and hiatal hernia repair with mesh implantation from January 2009 until December 2014 was interrogated. Ten patients with preoperative esophageal high resolution manometry and 24-hour pH impedance monitoring because of symptoms suggestive of GERD who received hiatal repair using dual-sided meshes in inlay technique were identified and included in this analysis.

RESULTS

There were no conversions to open surgery in the study group. Median operative time was 138 minutes (interquartile range Q1-Q3: 119-151 minutes) and average length of postoperative stay was 3.5 days (interquartile range Q1-Q3: 2.3-4.0 days). During a median follow-up period of 43.3 months (interquartile range Q1-Q3: 18.9-47.1 months), no redo operations had to be performed. Noteworthy, 2 patients complained about dysphagia (20%) during follow-up, but symptoms resolved after endoscopic interventions.

CONCLUSIONS

Tension-free inlay repair of large hiatal hernias using dual-sided composite PTFE/ePTFE meshes during LARS provides promising results. It provides satisfactory symptom relief and prolonged control of GERD. Further studies to validate its efficiency in a larger collective are needed.

The Optimal Approach to Symptomatic Paraesophageal Hernia Repair: Important Technical Considerations

While the asymptomatic paraesophageal hernia (PEH) can be observed safely, surgery is indicated for symptomatic hernias. Laparoscopic repair is associated with decreased morbidity and mortality; however, it is associated with a higher rate of radiologic recurrence when compared with the open approach. Though a majority of patients experience good symptomatic relief from laparoscopic repair, strict adherence to good technique is critical to minimize recurrence. The fundamental steps of laparoscopic PEH repair include adequate mediastinal mobilization of the esophagus, tension-free approximation of the diaphragmatic crura, and gastric fundoplication. Collis gastroplasty, mesh reinforcement, use of relaxing incisions, and anterior gastropexy are just a few adjuncts to basic principles that can be utilized and have been widely studied in recent years. In this article, we present a comprehensive review of literature addressing key aspects and controversies regarding the optimal approach to repairing paraesophageal hernias laparoscopically.

A Durable Laparoscopic Technique for the Repair of Large Paraesophageal Hernias

Laparoscopic repair of large paraesophageal hernias has been challenging due to high recurrence rates with primary repair and complications associated with the use of nonabsorbable mesh to reinforce the hiatus. The aim of our study was to evaluate the recurrence rate over time and mesh-related complications using an absorbable polyglactin mesh secured with Bioglue to reinforce the hiatus after laparoscopic repair of large paraesophageal hernias. There were 190 patients who met inclusion criteria from June 2006 to June 2014. Follow-up was routinely performed at 1-year intervals, including endoscopy and/or video esophagram, and the gastroesophageal reflux disease health-related quality of life questionnaire. Mean follow-up was 21 months (3–88). There were no incidences of mesh erosion. Recurrence was detected in 17 patients (15.3%), with a median time to recurrence of 23 months (8–67). Recurrence rate was estimated with the Kaplan-Meier method to be 2.9 ± 1.6 per cent, 11.6 ± 3.7 per cent, 22.4 ± 5.6 per cent, 25.1 ± 6.0 per cent, and 29.5 ± 7.9 per cent at 12, 24, 36, 48, and 60 months, respectively. The mean gastroesophageal reflux disease health-related quality of life was 2 in patients both with and without recurrence. Laparoscopic intrathoracic stomach repair using absorbable polyglactin mesh and Bioglue for crural reinforcement is effective, safe, and durable. The rate of recurrence plateaus over time with the majority of recurrences being small to moderate asymptomatic hernias.

An immobilized liquid interface prevents device associated bacterial infection in vivo

Virtually all biomaterials are susceptible to biofilm formation and, as a consequence, device-associated infection. The concept of an immobilized liquid surface, termed slippery liquid-infused porous surfaces (SLIPS), represents a new framework for creating a stable, dynamic, omniphobic surface that displays ultralow adhesion and limits bacterial biofilm formation. A widely used biomaterial in clinical care, expanded polytetrafluoroethylene (ePTFE), infused with various perfluorocarbon liquids generated SLIPS surfaces that exhibited a 99% reduction in S. aureus adhesion with preservation of macrophage viability, phagocytosis, and bactericidal function. Notably, SLIPS modification of ePTFE prevents device infection after S. aureus challenge in vivo, while eliciting a significantly attenuated innate immune response. SLIPS-modified implants also decrease macrophage inflammatory cytokine expression in vitro, which likely contributed to the presence of a thinner fibrous capsule in the absence of bacterial challenge. SLIPS is an easily implementable technology that provides a promising approach to substantially reduce the risk of device infection and associated patient morbidity, as well as health care costs.

Laparoscopic surgical treatment of esophageal hiatal hernia

Types II, III and IV esophageal hiatal hernia (EHH) which presents obvious symptoms or leads to potentially fatal complications requires surgical treatment. Laparoscopy has been used to repair EHH in the last two decades globally and proved to be minimally invasive compared to conventional open surgery. This review summarizes current status and prospectives of laparoscopic application in EHH treatment. The published articles on minimally invasive laparoscopic surgical treatment of EHH in PubMed, Cochrane Library and EMBASE databases were retrieved and analyzed. From 1992 to 2015, 86 English articles involving a total of 4771 patients receiving laparoscopic treatment for EHH were retrieved. Perioperative information including safety and feasibility of procedure, postoperative complications, and short/long-term outcome after laparoscopic repair was retrospectively analyzed. Laparoscopic surgical treatment of EHH is a safe, feasible and minimally invasive procedure with fast recovery after repair, low postoperative morbidity and recurrence.

Laparoscopic repair of hiatus hernia: Does mesh type influence outcome? A meta-analysis and European survey study

BACKGROUND

Synthetic mesh (SM) has been used in the laparoscopic repair of hiatus hernia but remains controversial due to reports of complications, most notably esophageal erosion. Biological mesh (BM) has been proposed as an alternative to mitigate this risk. The aim of this study is to establish the incidence of complications, recurrence and revision surgery in patients following suture (SR), SM or BM repair and undertake a survey of surgeons to establish a perspective of current practice.

METHODS

An electronic search of EMBASE, MEDLINE and Cochrane database was performed. Pooled odds ratios (PORs) were calculated for discrete variables. To survey current practice an online questionnaire was sent to emails registered to the European Association for Endoscopic Surgery.

RESULTS

Nine studies were included, comprising 676 patients (310 with SR, 214 with SM and 152 with BM). There was no significant difference in the incidence of complications with mesh compared to SR (P = 0.993). Mesh significantly reduced overall recurrence rates compared to SR [14.5 vs. 24.5 %; POR = 0.36 (95 % CI 0.17-0.77); P = 0.009]. Overall recurrence rates were reduced in the SM compared to BM groups (12.6 vs. 17.1 %), and similarly compared to the SR group, the POR for recurrence was lower in the SM group than the BM group [0.30 (95 % CI 0.12-0.73); P = 0.008 vs. 0.69 (95 % CI 0.26-1.83); P = 0.457]. Regarding surgical technique 503 survey responses were included. Mesh reinforcement of the crura was undertaken by 67 % of surgeons in all or selected cases with 67 % of these preferring synthetic mesh to absorbable mesh. One-fifth of the respondents had encountered mesh erosion in their career.

CONCLUSIONS

Both SM and BM reduce rates of recurrence compared to SR, with SM proving most effective. Surgical practice is varied, and there remains insufficient evidence regarding the optimum technique for the repair of hiatal hernia.

An unusual cause for halitosis

This report describes an unusual cause for halitosis and an unusual treatment for the underlying problem. Halitosis is a symptom which can result from a diverse range of underlying pathologies, most frequently those affecting the oral cavity or respiratory tract. Uncommonly, it arises due to pathology within the upper gastrointestinal tract. The case of a patient presenting with severe persistent halitosis attributable to mesh erosion occurring 8 years after redo laparoscopic hiatus hernia repair is described. Full external healing of the erosion tract was observed such that no symptomatic oesophageal perforation resulted. Mesh erosion is typically managed with surgical intervention. In this case, the infected mesh was successfully removed endoscopically.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution

BACKGROUND

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH.

MATERIALS AND METHODS

Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively.

RESULTS

Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic.

CONCLUSIONS

This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Surgical treatment of GERD. Comperative study of WTP vs. Toupet fundoplication - results of 151 consecutive cases

INTRODUCTION

Gastroesophageal reflux disease (GERD) is recognized as one of the most common disorders of the upper gastrointestinal tract (GIT). The best choice of management for advanced GERD is laparoscopic surgery.

AIM

To compare and evaluate the results of surgical treatment of GERD patients operated on using two different techniques.

MATERIAL AND METHODS

Between 2001 and 2012, 353 patients (211 female and 142 male), aged 17-76 years (mean 44), underwent laparoscopic antireflux surgery. The study included patients who underwent a Toupet fundoplication or Wroblewski Tadeusz procedure (WTP).

RESULTS

The mean age of the group was 47.77 years (17-80 years). Forty-nine (32.45%) patients had severe symptoms, 93 (61.58%) had mild symptoms and 9 (5.96%) had a single mild but intolerable sign of GERD. Eighty-six (56.95%) patients had a Toupet fundoplication and 65 (43.04%) had a WTP. The follow-up period was 18-144 months. The average operating time for Toupet fundoplication and the WTP procedure was 164 min (90-300 min) and 147 min (90-210 min), respectively. The perioperative mortality rate was 0.66%. The average post-operative hospitalization period was 5.4 days (2-16 post-operative days (POD) = Toupet) vs. 4.7 days (2-9 POD = WTP). No reoperations were performed. No major surgical complications were identified.

CONCLUSIONS

Wroblewski Tadeusz procedure due to a low percentage of post-operative complications, good quality of life of patients and a zero recurrence rate of hiatal hernia should be a method of choice.

Quality of Life Following Repair of Large Hiatal Hernia is Improved but not Influenced by Use of Mesh: Results From a Randomized Controlled Trial

INTRODUCTION

Laparoscopic surgery is the treatment of choice for repair of large hiatus hernia, but can be followed by recurrence. Repair with prosthetic mesh has been recommended to prevent recurrence, although complications following mesh repair have generated disagreement about whether or not mesh should be used. The early objective and clinical results of a randomized trial of repair with mesh versus sutures have been reported, and revealed few differences. In the current study, we evaluated quality of life outcomes within this trial at follow-up to 2 years.

METHODS

In a multicenter prospective double-blind randomized trial three methods for repair of large hiatus hernia were compared: sutures versus repair with absorbable mesh (Surgisis) versus non-absorbable (Timesh). Quality of life assessment using the Short-Form 36 (SF-36) questionnaire was undertaken at 3, 6, 12 and 24 months after surgery. SF-36 outcomes (8 individual scales and 2 composite scales) were determined for each group, and compared between groups, and across different follow-up points.

RESULTS

126 patients were enrolled-43 sutures, 41 absorbable mesh and 42 non-absorbable mesh. 115 (91.3%) completed a preoperative questionnaire, and 113 (89.7%) completed the post-operative questionnaire at 3 months, 116 (92.1%) at 6 months, 114 (90.5%) at 12 months, and 91 (72.2%) at 24 months. The SF-36 Physical and Mental Component Scores (PCS and MCS) improved significantly following surgery, and this improvement was sustained across 24 months follow-up (p < 0.001 for PCS and MCS at each follow-up point). There were no significant differences between the groups for the component scores or the eight SF-36 subscale scores at each follow-up time. 29 individuals had a recurrence at 6 months follow-up, of which 9 were symptomatic. The PCS were higher in patients with recurrence versus without (p < 0.01), and in patients with a symptomatic recurrence versus asymptomatic recurrence versus no recurrence (p = 0.001).

CONCLUSION

SF-36 measured quality of life improved significantly after repair of large hiatal hernia at up to 2 years follow-up, and there were no differences in outcome for the different repair techniques. The use of mesh versus no mesh in repair of large hiatal hernia did not influence quality of life.

The Use of Biological Meshes in Diaphragmatic Defects - An Evidence-Based Review of the Literature

The widespread use of meshes for hiatal hernia repair has emerged in the era of laparoscopic surgery, although sporadic cases of mesh augmentation of traumatic diaphragmatic rupture have been reported. The indications for biologic meshes in diaphragmatic repair are ill defined. This systematic review aims to investigate the available evidence on the role of biologic meshes in diaphragmatic rupture and hiatal hernia repair. Limited data from sporadic case reports and case series have demonstrated that repair of traumatic diaphragmatic rupture with biologic mesh is safe technique in both the acute or chronic setting. High level evidence demonstrates short-term benefits of biologic mesh augmentation in hiatal hernia repair over primary repair, although adequate long-term data are not currently available. Long-term follow-up data suggest no benefit of hiatal hernia repair using porcine small intestine submucosa over suture repair. The effectiveness of different biologic mesh materials on hernia recurrence requires further investigation.

Use of Mesh in Laparoscopic Paraesophageal Hernia Repair: A Meta-Analysis and Risk-Benefit Analysis

Introduction

Mesh augmentation seems to reduce recurrences following laparoscopic paraesophageal hernia repair (LPHR). However, there is an uncertain risk of mesh-associated complications. Risk-benefit analysis might solve the dilemma.

Materials and Methods

A systematic literature search was performed to identify randomized controlled trials (RCTs) and observational clinical studies (OCSs) comparing laparoscopic mesh-augmented hiatoplasty (LMAH) with laparoscopic mesh-free hiatoplasty (LH) with regard to recurrences and complications. Random effects meta-analyses were performed to determine potential benefits of LMAH. All data regarding LMAH were used to estimate risk of mesh-associated complications. Risk-benefit analysis was performed using a Markov Monte Carlo decision-analytic model.

Results

Meta-analysis of 3 RCTs and 9 OCSs including 915 patients revealed a significantly lower recurrence rate for LMAH compared to LH (pooled proportions, 12.1% vs. 20.5%; odds ratio (OR), 0.55; 95% confidence interval (CI), 0.34 to 0.89; p = 0.04). Complication rates were comparable in both groups (pooled proportions, 15.3% vs. 14.2%; OR, 1.02; 95% CI, 0.63 to 1.65; p = 0.94). The systematic review of LMAH data yielded a mesh-associated complication rate of 1.9% (41/2121; 95% CI, 1.3% to 2.5%) for those series reporting at least one mesh-associated complication. The Markov Monte Carlo decision-analytic model revealed a procedure-related mortality rate of 1.6% for LMAH and 1.8% for LH.

Conclusions

Mesh application should be considered for LPHR because it reduces recurrences at least in the mid-term. Overall procedure-related complications and mortality seem to not be increased despite of potential mesh-associated complications.

A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair

BACKGROUND

Equipoise exists regarding whether mesh cruroplasty during laparoscopic large hiatal hernia repair improves symptomatic outcomes compared with suture repair.

DATA SOURCE

Systematic literature review (MEDLINE and EMBASE) identified 13 studies (1,194 patients; 521 suture and 673 mesh) comparing mesh versus suture cruroplasty during laparoscopic repair of large hiatal hernia. We abstracted data regarding symptom assessment, objective recurrence, and reoperation and performed meta-analysis.

CONCLUSIONS

The majority of studies reported significant symptom improvement. Data were insufficient to evaluate symptomatic versus asymptomatic recurrence. Time to evaluation was skewed toward longer follow-up after suture cruroplasty. Odds of recurrence (odds ratio .51, 95% confidence interval .30 to .87; overall P = .014) but not need for reoperation (odds ratio .42, 95% confidence interval .13 to 1.37; overall P = .149) were less after mesh cruroplasty. Quality of evidence supporting routine use of mesh cruroplasty is low. Mesh should be used at surgeon discretion until additional studies evaluating symptomatic outcomes, quality of life, and long-term recurrence are available.

First human magnetic resonance visualisation of prosthetics for laparoscopic large hiatal hernia repair

PURPOSE

Mesh repair of large hiatal hernias has increasingly gained popularity to reduce recurrence rates. Integration of iron particles into the polyvinylidene fluoride mesh-based material allows for magnetic resonance visualisation (MR).

METHODS

In a pilot prospective case series eight patients underwent surgical repair of hiatal hernias repair with pre-shaped meshes, which were fixated with fibrin glue. An MR investigation with a qualified protocol was performed on postoperative day four and 3 months postoperatively to evaluate the correct position of the mesh by assessing mesh appearance and demarcation. The total MR-visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces.

RESULTS

We documented no mesh migrations or dislocations but we found a significant decrease of MR-visualised total mesh surface area after release of the pneumoperitoneum compared to the original mesh size (mean 78.9 vs 84 cm(2); mean reduction of mesh area = 5.1 cm(2), p < 0.001). At 3 months postoperatively, a further reduction of the mesh surface area could be observed (mean 78.5 vs 78.9 cm(2); mean reduction of mesh area = 0.4 cm(2), p < 0.037).

CONCLUSION

Detailed mesh depiction and accurate assessment of the surrounding anatomy could be successfully achieved in all cases. Fibrin glue seems to provide effective mesh fixation. In addition to a significant early postoperative decrease in effective mesh surface area a further reduction in size occurred within 3 months after implantation.