Characterization of Crural Repair in Antireflux Surgery: Preliminary Experience with a Standardized Technique

Abstract

Purpose: To define and optimize cruroplasty in laparoscopic repair of hiatal hernia (LRHH). Background: Crural closure and crural repair in LRHH are used interchangeably. While crural closure entails obliteration of the diaphragmatic defect, cruroplasty involves restoring the anatomy and producing a “functional closure.” Methods: This is an IRB-approved retrospective study. Inclusion criteria were sliding hiatal hernia ≤6 cm in axial length, abnormal pH study or erosive esophagitis, use of the endostitch device to standardize surgical bite, and endoscopic fundoplication to standardize the wrap. Exclusion criteria were a history of antireflux surgery, gastroparesis, or preexisting esophageal stricture. Results: A total of 68 patients, 21 males, and 47 females met the inclusion criteria. The median age and BMI were 59 and 28, respectively. The average follow-up was 26.3 (12–62) months. There were three anatomical recurrences 3/68 (4.4%) and two of them had symptomatic recurrence. All but eight patients discontinued antisecretory therapy 60/68 (88.2%). Five of these eight patients used these medications at lesser dose or frequency rendering the overall improvement of patients to 65/68 (95.5%). There was no postoperative dysphagia. Conclusions: Laparoscopic hiatal hernia repair should focus on crural repair, not merely closure. Optimizing cruroplasty can be achieved by understanding the functional anatomy, recreating the crural sling, and adjusting the crural suture tension. This results in a low recurrence rate of hiatal hernias, a high discontinuation rate of proton pump inhibitors, significant objective clinical improvement of GERD symptoms, and no postoperative dysphagia.