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Chaudhry S, Farsi S, Nakanishi H, Parmar C, Ghanem OM, Clapp B. Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2024:00129689-990000000-00245. [PMID: 38946644 DOI: 10.1097/sle.0000000000001295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/16/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS). MATERIALS AND METHODS CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. RESULTS Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I2 = 0%, n = 21). CONCLUSION Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.
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Affiliation(s)
- Shahrukh Chaudhry
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Soroush Farsi
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
| | - Hayato Nakanishi
- St George's University of London
- University College London Hospital, London, UK
| | - Chetan Parmar
- University College London Hospital, London, UK
- University of Nicosia Medical School, University of Nicosia, Nicosia, Cyprus
| | | | - Benjamin Clapp
- Department of Surgery, Texas Tech HSC Paul Foster School of Medicine, El Paso, TX
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Vigneswaran Y, Hussain M, Varsanik MA, Corvin C, Gottlieb LJ, Alverdy JC. IDEAL Phase 2a Results: Posterior Rectus Sheath Flap for Hiatal Augmentation in Complex Paraesophageal Hernias. Ann Surg 2024; 279:1000-1007. [PMID: 38375674 PMCID: PMC11086674 DOI: 10.1097/sla.0000000000006247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
OBJECTIVE To report the developmental phase results of posterior rectus sheath hiatal flap augmentation (PoRSHA), a promising surgical innovation for large and recurrent paraesophageal hernias. BACKGROUND Durable hernia repair for large paraesophageal hernias continues to be a surgical challenge. PoRSHA addresses the challenges of current and historical approaches to complex paraesophageal hernias and demonstrates significant promise as a successful alternative approach. METHODS Using the IDEAL framework, we outline the technical modifications made over the first 27 consecutive cases using PoRSHA. Outcomes measured included hernia recurrence on routine imaging at 6 months and 2 years, development of a postoperative abdominal wall eventration and incidence of solid food dysphagia. RESULTS Twenty-seven patients at our single institution with type III (n=12), type IV (n=7), or recurrent (n=8) paraesophageal hernias underwent PoRSHA. Surgery was safely and successfully carried out in all cases. Stability of the technique was reached after 16 cases, resulting in 4 main repair types. At an average follow-up of 11 months, we observed no radiologic recurrences, no abdominal eventrations or hernias at the donor site, and 1 patient with occasional solid food dysphagia that resolved with dilation. CONCLUSIONS PoRSHA can not only be safely added to conventional hiatal hernia repair with appropriate training but also demonstrates excellent short-term outcomes. While the long-term durability with 5-year follow-up is still needed, here we provide cautious optimism that PoRSHA may represent a novel solution to the long-standing high recurrence rates observed with current complex PEH repair.
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Affiliation(s)
- Yalini Vigneswaran
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Mustafa Hussain
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - M. Alyssa Varsanik
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Chase Corvin
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Lawrence J. Gottlieb
- Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - John C. Alverdy
- Section of Minimally Invasive Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
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Cheng F, Liang H, Zhang Y, Zeng H, Gao X, Tan L, He H. Tension-free hiatal hernia repair with biological mesh: A real-world experience. Medicine (Baltimore) 2022; 101:e31782. [PMID: 36397386 PMCID: PMC9666108 DOI: 10.1097/md.0000000000031782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Laparoscopic Nissen fundoplication and esophagoplasty are the standards for gastroesophageal reflux disease (GERD) and hiatal hernia (HH) repair. Biologically derived mesh is also associated with reduced recurrence. This study attempted to evaluate the effectiveness of a biological mesh in the 4K laparoscopic repair of HH. This retrospective study reviewed patients with a severe GERD complicated with HH from August 2019 to August 2020. All patients underwent the HH repair using a biological mesh under a 4K laparoscope accompanying Nissen fundoplication. Up to 16 months postoperatively, GERD-health-related quality-of-life (GERD-HRQL) scale, radiologic studies on HH recurrence, and symptoms were recorded. The mean surgical time and postoperative hospital stay were 70.9 ± 8.72 min, 4.8 ± 0.76 days, respectively. The postoperative symptom relief rate was 96.5%, and no recurrence exhibited during follow-up. Dysphagia occurred in 10 (9.43%) patients. There were no intraoperative vagus nerve injury or postoperative complications, mesh infection, and reoperation for mesh. The tension-free repair of HH with the biological mesh is an option for clinical use, with effectiveness and few short-term complications being reported.
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Affiliation(s)
- Fahui Cheng
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hongyan Liang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Yu Zhang
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hui Zeng
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Xiao Gao
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Lipeng Tan
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
| | - Hengzheng He
- Department of Mini-Invastsurgery, Brain Hospital of Hunan Province (The Second People’s Hospital of Hunan Province), Changsha, Hunan, China
- * Correspondence: Hengzheng He, Department of Mini-invastsurgery, Brain Hospital of Hunan Province, 427, third segment, Furong Zhong Road, Changsha, Hunan 410007, China (e-mail: )
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Ligamentum teres augmentation (LTA) for hiatal hernia repair after minimally invasive esophageal resection: a new use for an old structure. Langenbecks Arch Surg 2021; 406:2521-2525. [PMID: 34611750 PMCID: PMC8578099 DOI: 10.1007/s00423-021-02284-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/18/2021] [Indexed: 01/07/2023]
Abstract
Purpose Hiatal hernias with intrathoracic migration of the intestines are serious complications after minimally invasive esophageal resection with gastric sleeve conduit. High recurrence rates have been reported for standard suture hiatoplasties. Additional mesh reinforcement is not generally recommended due to the serious risk of endangering the gastric sleeve. We propose a safe, simple, and effective method to close the hiatal defect with the ligamentum teres. Methods After laparoscopic repositioning the migrated intestines, the ligamentum teres is dissected from the ligamentum falciforme and the anterior abdominal wall. It is then positioned behind the left lobe of the liver and swung toward the hiatal orifice. Across the anterior aspect of the hiatal defect it is semi-circularly fixated with non-absorbable sutures. Care should be taken not to endanger the blood supply of the gastric sleeve. Results We have used this technique for a total of 6 patients with hiatal hernias after hybrid minimally invasive esophageal resection in the elective (n = 4) and emergency setting (n = 2). No intraoperative or postoperative complications have been observed. No recurrence has been reported for 3 patients after 3 months. Conclusion Primary suture hiatoplasties for hiatal hernias after minimally invasive esophageal resection can be technically challenging, and high postoperative recurrence rates are reported. An alternative, safe method is needed to close the hiatal defect. Our promising preliminary experience should stimulate further studies regarding the durability and efficacy of using the ligamentum teres hepatis to cover the hiatal defect. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02284-9.
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Asti E, Lovece A, Bernardi D, Milito P, Manzo CA, Bonavina L. Falciform Ligament Flap as Crural Buttress in Laparoscopic Hiatal Hernia Repair. J Laparoendosc Adv Surg Tech A 2021; 31:738-742. [PMID: 33970030 DOI: 10.1089/lap.2021.0244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Crural repair is an essential technical component in laparoscopic hiatal hernia surgery, but there is no consensus regarding the optimal method to prevent postoperative hernia recurrence. Mesh augmentation, especially with permanent materials, is associated with dysphagia and complications. The rotational falciform ligament flap (FLF) has been reported to be effective in reinforcing standard suture closure of the hiatus. Materials and Methods: Patients with primary or secondary hiatal hernia in whom FLF was used to buttress the hiatus repair were included. The FLF was dissected from the anterior abdominal wall, detached from the umbilical area, and transposed below the left lateral liver segment to buttress the cruroplasty. Indocyanine green fluorescence was used to assess vascularization of the flap before and after mobilization. Results: Eighteen consecutive patients underwent laparoscopic FLF cruroplasty reinforcement between October 2019 and January 2021. Indications were primary hiatal hernia (n = 9), recurrent hiatal hernia (n = 4), postsleeve gastrectomy hernia (n = 1), prophylactic hiatal repair during esophagectomy and gastric conduit reconstruction (n = 2), and postesophagectomy hernia (n = 2). All flaps were well vascularized and covered the entire hiatal area. There was no morbidity. At a median follow-up of 8 months (range 3-15), the symptomatic and quality of life scores significantly improved compared with baseline (P < .001), and no anatomic hernia recurrences were detected. Conclusions: FLF is safe for crural buttress and is a viable alternative to mesh in laparoscopic hiatal hernia surgery.
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Affiliation(s)
- Emanuele Asti
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
| | - Andrea Lovece
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
| | - Daniele Bernardi
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
| | - Pamela Milito
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
| | - Carlo Alberto Manzo
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
| | - Luigi Bonavina
- Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese (Milano), Italy
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Baskaran V, Banerjee JK, Ghosh SR, Kumar SS, Anand S, Menon G, Mishra DS, Saranga Bharathi R. Applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery-a review of their utility and efficacy. Langenbecks Arch Surg 2021; 406:1249-1281. [PMID: 33411036 DOI: 10.1007/s00423-020-02031-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 11/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND PURPOSE Despite their ubiquitous presence, easy availability and diverse possibilities, falciform ligament and hepatic round ligament have been used less frequently than their potential dictates. This article aims to comprehensively review the applications of hepatic round ligament/falciform ligament flap and graft in abdominal surgery and assess their utility and efficacy. METHODS Medical literature/indexing databases were searched, using internet search engines, for pertinent articles and analysed. RESULTS The studied flap and graft have found utility predominantly in the management of diaphragmatic hernias, gastro-oesophageal reflux disease, peptic perforations, biliary reconstruction, venous reconstruction, post-operative pancreatic fistula, post-pancreatectomy haemorrhage, hepatic cyst cavity obliteration, liver bleed, sternal dehiscence, splenectomy, reinforcement of aortic stump, feeding access, diagnostic/therapeutic access into portal system, composite tissue allo-transplant and ventriculo-peritoneal shunting where they have exhibited the desired efficacy. CONCLUSIONS Hepatic round ligament/falciform ligament flap and graft are versatile and have multifarious applications in abdominal surgery with some novel and unique uses in hepatopancreaticobiliary surgery including liver transplantation. Their evident efficacy needs wider adoption to realise their true potential.
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Affiliation(s)
| | - Jayant Kumar Banerjee
- Department of Gastro-intestinal Surgery, Bharati Vidyapeeth Medical College, Pune, India
| | - Sita Ram Ghosh
- Department of Gastro-intestinal Surgery, Command Hospital (Eastern Command), Kolkata, India
| | - Sukumar Santosh Kumar
- Department of Gastro-intestinal Surgery, Command Hospital (Central Command), Lucknow, Uttar Pradesh, 226002, India
| | | | - Govind Menon
- Department of Plastic & Reconstructive Surgery, Command Hospital (Central Command), Lucknow, India
| | | | - Ramanathan Saranga Bharathi
- Department of Gastro-intestinal Surgery, Command Hospital (Central Command), Lucknow, Uttar Pradesh, 226002, India.
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Utilization of the Falciform Ligament to Buttress the Pancreatic Transection Staple Line: A Novel Technique. Surg Laparosc Endosc Percutan Tech 2020; 30:e39-e42. [PMID: 32941356 DOI: 10.1097/sle.0000000000000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) remains a common complication after distal pancreatectomy and is a major source of operative morbidity. Although various mechanical, biological, and synthetic aids have been used to reduce the risk of POPF, none have a proven benefit. MATERIALS AND METHODS The authors describe (and present a video, Supplemental Digital Content 1, http://links.lww.com/SLE/A256) a novel technique in which the autologous falciform ligament was harvested, wrapped around the pancreas at the site of proposed pancreatic transection, and secured with sutures to buttress the pancreatic transection staple line. The pancreas was then transected with a triple-row stapler. RESULTS Two male patients aged 40 and 57 years each with a 4.3 and 4.2 cm solid mass in the body of the pancreas respectively underwent laparoscopic anterior radical antegrade modular pancreaticosplenectomy, the former patient underwent an en block transverse colectomy for suspected malignancy. Both patients had soft pancreata. They experienced no POPF, made an uneventful recovery, and were discharged from the hospital on the second and fourth postoperative days, respectively. No pancreatic complications were encountered at 5 and 6 months follow-up, respectively. CONCLUSIONS The use of the falciform ligament to buttress the staple line at the time of pancreatic transection is a novel technique. Its potential benefit in reducing the risk of POPF warrants further assessment.
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