Laparoscopic repair of type III/IV giant para-oesophageal herniae with biological prosthesis: a single centre experience

Abstract

Repair of giant paraoesophageal herniae (GPEH) is technically challenging and requires significant experience in advanced foregut surgery. Controversy continues on suture versus mesh cruroplasty with the most recent systematic review and meta-analysis putting the onus on the operating surgeon. Study aim was to review whether the biological prosthesis (non-cross-linked bovine pericardium and porcine dermis) and the technique adopted for patients with GPEH had an influence on clinical and radiological recurrences. A retrospective analysis of a prospectively collected data of 60 consecutive patients with confirmed 5cm hiatus hernia and ≥ 30% stomach displacement in the thorax that were operated in the upper gastrointestinal unit of a large district general hospital between September 2010 and August 2017. Pre and post-surgery Gastro-Oesophageal Reflux Disease Questionnaire [(GORD-HRQOL)] and a follow up contrast study were completed. 60 included 2 (3%) and 58 (97%) emergency and elective procedures respectively with a male: female ratio of 1:3, age 71* (Median) (42-89) years, BMI 29* (19-42) and 26 (43%) with ASA III/IV. Investigations confirmed 46* (37-88) mm and 42* (34-77) mm transverse and antero-posterior hiatal defect respectively with 60* (30-100)% displacement of stomach into chest. Operative time and length of stay was 180* (120-510) minutes and 2* (1-30) days respectively. One (2%) converted for bleeding and 2 (3%) peri-operative deaths. Five (8%), 5 (8%) and 4 (7%) have dysphagia, symptomatic and radiological recurrences respectively. GORD-HRQOL recorded preoperatively was 27* (10-39) dropping significantly postoperatively to 0* (0-21) (P < 0.005) with 95% patient satisfaction at a follow up of 60* (36-84) months. Our technique of laparoscopic GPEH repair with biological prosthesis is safe with a reduced symptomatic and radiological recurrence and an acceptable morbidity and mortality.