Laparoscopic Repair Of Large Hiatal Hernia And Applied Value Of The Mesh

Objective:To investigate laparoscopic repair of large hiatal hernia and applied value of the mesh.Methods:72patients with large hiatal hernia underwent laparoscopic repair of large hiatal hernia in minimally invasive center of NanKai hospital, Jan2007to Dec2011.72patients were randomized into two groups, among which no mesh was used in25patients from Jan2007to Oct2008.The clinical outcomes of these patients were compared with other47patients with mesh repair from Nov2008to Dec2011. The two groups of surgeons have similar clinical experience, such as laparoscopic hernia repair technique.The patients were evaluated before and after surgery, including gastroscopy, barium swallow,esophageal manometry,24-h pH monitoring and follow-up results.We analysed the indexes and observed the effectiveness of laparoscopic large hiatal hernia repair and the mesh.Results:All laparoscopic surgeries were accomplished successfully. No laparotomy and deaths occurred. In all72cases,69cases were followed up and3were lost. Follow-up of69cases,64cases after surgery had the above examinations,5cases did not due to personal reasons.Follow-up of62months (mean29.5months). Radiological and endoscopic assessment were routinely performed at the1st month after surgery, no recurrence.Through the analysis for64patients, we found that the mesh group of42cases had a lower symptomatic recurrence rate (2.4%:18.2%;P=0.025), and hernia recurrence rate (0%:9.1%; P=0.047) than the non-mesh group of25patients.In the mesh group,41cases had complete remission of symptoms,and no recurrence during follow-up;1cases in the8th months after surgery had acid reflux, heartburn, no hernia recurrence and controlled by acid-suppressing drugs.3cases after surgery had a dysphagia, confirmed the lower esophageal stricture or erosion.2cases of stricture underwent endoscopic balloon dilatation,1cases of erosion underwent laparotomy for esophagus resection and esophagogastrostomy.In non-mesh group,18cases had complete remission of symptoms,and no recurrence during follow-up;6months after surgery(mean10.5months),4cases had acid reflux and heartburn,2cases had small part of the gastric fundus herniated into the chest, considered hernia recurrence.1case had a reoperative laparoscopic repair with the mesh,,but3cases refused further surgical treatment and with acid-suppressing drugs.1case after surgery had a dysphagia, confirmed the lower esophageal stricture and underwent endoscopic balloon dilatation.Conclusions:Laparoscopic repair of large hiatal hernia had less surgical trauma, less bleeding and more rapid recovery advantage.Short-term follow-up the majority of patients can relieve symptoms. The method is safe,feasible and effective.The use of mesh can reduce the difficulty of repair of hiatal hiatus and reduce recurrence, but still need to accumulate clinical data and long-term follow-up. But the mesh has some complications. A number of controversies are associated with such use,including the indication for mesh placement, the type of mesh to use, the configuration of the mesh with respect to the hiatus and esophagus, and how the mesh is anchored in place.In our view, selective application of mesh should be based on the situation, the indication for mesh placement is mainly for the large hernia with diameter of the hiatus more than5cm.The author believes that the application of mesh has some advantages for the large hernia with diameter of the hiatus more than5cm. Especially for the large hernia with diameter of the hiatus more than8cm, the relatively weak diaphragm, short esophagus, and older, accompanied by long-term cough likely to increase the abdominal pressure disease or recurrent hernia, it is recommended that the application of mesh repair to reduce the recurrence rate. There are the following points about the application with mesh to minimize mesh-related complications.The mesh positions posterior to the esophagus but not completely surrounding it. The placement of the mesh can not too close to the esophagus. For anchorage of the mesh to the crural bundles and diaphragm, stapling is the most common technique for us. If there is need of anti-flow operation, the270°Toupet fundoplication is preferred, to minimize the stimulation for the esophagus.