Study Of Technical Modification And Postoperative Improvement In Respiratory Function For Laparoscopic Large Hiatal Hernia Repair

Background: Large Hiatal Hernia(LHH)normally was defined as either 1/3 of stomach migrated into the thorax or a hiatal hernia measuring at least 5 cm in length. Laparoscopic repair HH(LRLHH) is gradually recommended,but it still is controversial, because of complicated, difficult and high-risk operation, high recurrence rate and the mesh of adverse events. The published literatures reported the recurrence rate of direct hiatus closure technique was high, up to 42%. Prosthesis mesh can reduce the recurrence rate, however, the use of mesh is associated with the mesh adverse events which were concerned in many literature recently, such as scarring response, severe adhesions, esophageal stenosis, upper digestive tract fistula, mesh displacement. Moreover, those adverse events usually caused a great impact on quality of life for those patients. In addition, we got a hypothesis is that LRLHH will lead to subjective and objective improvement the presence of preoperative dyspnea in most elderly patients with large hernias.Objective: The aim of the present study was to determine: 1. Modified technique of LRLHH(included dissecting the sac fully, approximation of the crura, fixed double surface compound mesh, routine fundoplication) is effective, safe and feasible in long-term; 2.control study in effectiveness and safety between mesh and without mesh in LRLHH; 3. To assesses the effect of LRLHH on respiratory function.Method: To analyze the database of 119 patients who undergone the LRLHH in Nankai Hospital from January 2006 to Auguest 2014. 1. The patients were grouped into modified technique vs non-modified technique, comparing, the success rate, postoperative morbidity, the subjective and objective long-term outcome were evaluated. 2. Controlled analysis, comparing mesh group with non-mesh group, the perioperative outcome, the recurrence rate and adverse event in long-term follow-up. 3. This study assesses the effect of LRLHH on post-operative respiratory function, comparing with preoperative pulmonary function tests.Results: 1.The total complication rate in modified group(n=52) was significant lower than that in non-modified group(n=67)(9.6% vs 23.9%,P =0.043). Higher incidence of mesh complication was observed in non-modified group compared withmodified group(n=5 vs n=0, P=0.067). Comparing to modified group, all of 4 recurrent HHs came from non-modified group(0% vs 6%, P=0.131). 2. Dysphagia remission rate in non-mesh group was significant higher than that in mesh group(P =0.039). The duration of follow-up was 32.7±12.6m in mesh group, 33.1±11.4m in non-mesh group.Comparing with the recurrence rate of HH between both groups, mesh group was lower than non-mesh group(1.2% vs 8.3%, P =0.082). 5 cases who accepted mesh reparie occurred mesh erosion, surgerical procedure dealed with 3 patients among of those. 3. The mean follow-up time of pulmonary function test(PFT) for 98 patients was 13.8±4.2m, including measured and percent predicted value of vital capacity(VC), forced expiratory voulme(FVC), forced expiratory volume in one second(FEV1). The postoperative PFTs were significant higher than preoperative PFTs. Patients were stratified analysis by percent of intrathoracic stomach(ITS%), we observed ITS% was only parameter statistical correlation with postoperative PFT improvement, the bigger ITS% trend to the better PFTs. Postoperative VC 、 FVC and FEV1 improvement were statistically significant difference both in 30%~50% ITS% group, except FVC, and in ITS%>50% group. The patients with preoperative dyspnea obtained statistically significant improvement in terms of VC、FVC and FEV1. Postoperative VC、FVC、FEV1 in 21 patients with preoperative chronic respiratory disease were improvement, comparing to preoperative PFTs, only improvement VC difference with statistical significance.Conclusion:1. The modified LRLHH group had more everlasting surgical effect,lower recurrent rate and mesh adverse event. 2. Lower recurrent incidence of HHs was observed in mesh group, and the new double composite mesh repair LHH could reduce the mesh adverse event. 3. LRLHH produce the postoperative PFTs improvement. Moreover ITS% was correlation with postoperative PFT improvement, the ITS% of 50% trend to the better PFTs.