Ligamentum teres augmentation (LTA) for hiatal hernia repair after minimally invasive esophageal resection: a new use for an old structure

Mira Runkel,Goran Marjanovic,Jasmina Kuvendjiska,Markus K Diener,Stefan Fichtner-Feigl

doi:10.1007/s00423-021-02284-9

Mira Runkel, Goran Marjanovic + Show 3 more

Open Access

https://doi.org/10.1007/s00423-021-02284-9

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Abstract

PurposeHiatal hernias with intrathoracic migration of the intestines are serious complications after minimally invasive esophageal resection with gastric sleeve conduit. High recurrence rates have been reported for standard suture hiatoplasties. Additional mesh reinforcement is not generally recommended due to the serious risk of endangering the gastric sleeve. We propose a safe, simple, and effective method to close the hiatal defect with the ligamentum teres.MethodsAfter laparoscopic repositioning the migrated intestines, the ligamentum teres is dissected from the ligamentum falciforme and the anterior abdominal wall. It is then positioned behind the left lobe of the liver and swung toward the hiatal orifice. Across the anterior aspect of the hiatal defect it is semi-circularly fixated with non-absorbable sutures. Care should be taken not to endanger the blood supply of the gastric sleeve.ResultsWe have used this technique for a total of 6 patients with hiatal hernias after hybrid minimally invasive esophageal resection in the elective (n = 4) and emergency setting (n = 2). No intraoperative or postoperative complications have been observed. No recurrence has been reported for 3 patients after 3 months.ConclusionPrimary suture hiatoplasties for hiatal hernias after minimally invasive esophageal resection can be technically challenging, and high postoperative recurrence rates are reported. An alternative, safe method is needed to close the hiatal defect. Our promising preliminary experience should stimulate further studies regarding the durability and efficacy of using the ligamentum teres hepatis to cover the hiatal defect.

Highlights

Invasive esophageal resection (MIE) has become the gold-standard technique for patients with malignant disease of the esophagus and the gastroesophageal junction, showing generally favourable results compared to the open approach [1,2,3]
We developed an innovative method of covering the post-Minimally invasive esophageal resection (MIE) hiatal defect by using a flap of the ligamentum teres hepatis
The technical difficulty and high recurrence rates after suturehiatoplasty and the risk associated with mesh-repair have led us to consider the use of the ligamentum teres hepatis for an alternative closure of the hiatal defect

Summary

Introduction

Invasive esophageal resection (MIE) has become the gold-standard technique for patients with malignant disease of the esophagus and the gastroesophageal junction, showing generally favourable results compared to the open approach [1,2,3]. Hiatal hernias (HH) after MIE are serious complications with an incidence of up to 10.2% [4,5,6] (Fig. 1). We developed an innovative method of covering the post-MIE hiatal defect by using a flap of the ligamentum teres hepatis. The ligamentum teres hepatis ( known as the round ligament of the liver) is the remnant of the obliterated umbilical vein. It is the free, inferior edge of the falciforme ligament which spans between the liver and the diaphragm and anterior abdominal wall. This paper is a step-by-step description of our uncomplicated technique of the laparoscopic ligamentum teres augmentation (LTA) for patients after esophageal resections. Adhesiolysis and dissection of the hiatal opening is carried out until both

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Discussion

Conclusion