Laparoscopic repair of paraesophageal hiatal hernia

Abstract

We read with interest the recent article on laparoscopic repair of paraesophageal hiatal hernia by Andujar et al. [1]. The authors reported a paraesophageal hernia recurrence rate of 5%; they also reported recurrence of a sliding hiatal hernia in an additional 20% of their patients. Most of these latter patients, however, were symptomatically improved after the index operation. Overall, 6% of the patients required reoperation for various treatment failures. In 2002 we reported a randomized control trial of minimally invasive repair of large hiatal hernia with and without prosthetic reinforcement [3]. The recurrence rate with prosthetic reinforcement was zero; without reinforcement, the recurrence rate was 22%. There were no reoperations in the prosthetic group. Although our term for the disease in question was ‘‘large hiatal hernia’’ and Andujar et al.’s term was ‘‘large paraesophageal hernia,’’ a close reading of the two manuscripts reveals that the two definitions basically describe the same pathology. Andujar et al. stated that they avoided the use of prosthetic in their repairs out of concern for mesh erosion into the esophagus. This concern probably is real if polypropylene is used at the esophageal hiatus [2], but we know of no published case of polytetrafluoroethylene erosion into this organ after cruroplasty reinforcement. We have used PTFE in 80 of these cases since 1995 without any erosive complication. We would suggest that prosthetic reinforcement during the repair of large hiatal hernia is safe, and results in lower recurrence rate compared to cruroplasty without prosthetic reinforcement.