Crural Repair Research Articles

Comparative analysis of robotic and laparoscopic techniques in hiatal hernia and crural repair: a review of current evidence and outcomes.

The purpose of this narrative review is to evaluate the implementation of robotic surgery in hiatal hernia and crural repair, based on the existing literature and to compare this approach to other established techniques. We performed a non- systematic literature search of PubMed and MEDLINE on February 25, 2024 for papers published to date focusing on the surgical repair of hiatal hernias using the robotic platform. After eliminating publications based on eligibility criteria, 13 studies were selected for analysis. Robotic surgery is increasingly utilized in hiatal hernia repair due to its enhanced ergonomics and superior visualization capabilities. Operative times vary, with some studies indicating longer durations for robotic surgery (e.g., Giovannetti et al. demonstrated median operative time of 196min for robotic compared to 145min for laparoscopic) while others report shorter times (e.g., Lang F et al. demonstrated 88min for robotic versus 102min for laparoscopic). Recurrence rates between robotic and laparoscopic repairs are comparable, with reported recurrence rates of 1.8% for robotic and 1.2% for laparoscopic approaches by Benedix et al. Robotic surgery offers potential advantages, including reduced intraoperative blood loss (e.g., Giovannetti et al. mentioned median blood loss of 20ml for robotic versus 50ml for laparoscopic). The length of hospital stay and postoperative complication rates also vary, with some studies suggesting shorter stays and fewer complications for robotic surgery as surgeons become more proficient. Soliman et al. reported a statistically significant reduction in complication rates with robotic surgery (6.3% versus 19.2%). Robotic surgery presents promising results regarding the length of hospital stay, conversion rate to open surgery and postoperative complication rates when compared to laparoscopy based on the existing literature. Despite the lack of striking differences, robotic hiatal hernia repair is a valid and evolving approach.

Utility of falciform ligament flap for hiatal hernia repair: a systematic review.

Surgical repair of hiatal hernia (HH) is plagued by high recurrence rates. Hiatoplasty failure has been identified as a major determinant of recurrent symptoms and HH, but there is no consensus on the optimal surgical approach to minimize this complication and hiatal mesh reinforcement remains controversial. The use of the falciform ligament as an autologous rotational flap to support crural repair has been proposed as a potential solution. This review aims to evaluate the safety and efficacy of the falciform ligament flap (FLF) as an adjunct in HH repair. Searches were conducted on Google, Google Scholar, PubMed, Scopus, Web of Science, and Cochrane through May 2024. The primary study outcome was HH recurrence rate. Secondary outcomes included 30-day mortality rate, postoperative morbidity, and length of hospital stay. Descriptive statistics were used to analyze the data. Twelve studies comprising 469 patients undergoing FLF augmentation during primary or revisional HH repair were included. The majority (80.7%) of patients had HH types III-IV. Crural suture hiatoplasty was performed in all cases, and adjunctive mesh reinforcement was reported in two studies. Postoperative morbidity was 4.6%, and there was no mortality. The overall HH recurrence rate was 5.8% (range 0-15.4%). Our study seems to suggest that FLF may reduce postoperative HH recurrence. Well designed and comparative studies with long-term follow-up are required to confirm these preliminary data.

613. LAPAROSCOPIC MANAGEMENT OF TYPE IV HIATAL HERNIA WITH MESH AUGMENTATION CRUROPLASTY - EXPERIENCE AT A TERTIARY CARE CENTRE

Abstract Background Type IV para-esophageal hernias, which are characterized by herniation of other organs in addition to stomach, are rare - comprising only 2-5% of all para-esophageal hernias. They are associated with life-threatening complications such as strangulation or perforation of stomach. Laparoscopic treatment of these hernias requires excellent advanced laparoscopic suturing and dissecting skills. Although laparoscopic approach is now universally accepted, the role of mesh augmentation remains debated. Methods Case records of patients who underwent Laparoscopic mesh augmentation cruroplasty for Type IV hiatal hernia since 2012 were retrospectively analyzed. Results Out of 340 patients who underwent hiatal hernia repair, 7 patients (3males, 4females) fulfilled the selection criteria. Median age was 64(53-89) years. Median duration of symptoms was 2months (15days-6months). All patients complained of heartburn. Vomiting was present in 5(71%) patients; only 1(14%) patient had persistent vomiting with dysphagia. Respiratory symptoms were present in 2(29%) patients. No patient had features of peritonitis or sepsis. One patient had undergone laparoscopic heller’s cardiomyotomy twice before. All patients underwent MDCT which confirmed type IV paraesophageal hernia. Median operating time was 150(100-280) minutes. Median blood loss was 150(50-400) ml. 6(85%) patients had herniation of omentum in addition to stomach while 1 patient had herniation of omentum and transverse colon. No patient had ischemia/perforation of stomach. Median hiatal defect was 6(5-8) cm. Sac was excised completely in all cases following reduction of contents. Crural repair was done with1-0 polyester interrupted sutures. In some patients, anterior cruciate ligament repair was done to avoid tenting of esophagus. Rectangle shaped Composite mesh with key-hole slit in upper border was placed. Mesh was anchored with interrupted 1-0ethilon sutures. Fundoplication (Nissen’s/Toupet) was done in all patients, none required esophageal lengthening procedure. Median post-operative stay was 5(2-8) days, median ICU stay was 1(0-4) days. Oral liquids were started on 2 nd (1-3) post-op day and solids on 4 th (2-5) day. 2(29%) patients had post- operative complications - atrial fibrillation and transient respiratory failure respectively. Median follow-up was 14(1-40) months. No patient had symptomatic recurrence. OGDscopy at 6months was normal in 5 patients. No mesh related complication was observed. Discussion Wide hiatal defects were noted in all patients. This necessitated mesh augmentation of crural repair. Both short-term (morbidity, mortality) and long-term outcomes (recurrence, patient satisfaction) were excellent.

801. ROBOTIC ASSISTED LAPAROSCOPIC GIANT PARA-OESOPHAGEAL HERNIA REPAIR: 5-YEAR EXPERIENCE

Abstract Background Prior to laparoscopic era, giant paraesophageal hernia repair (GPEHR) was considered a relatively morbid operation requiring thoracotomy or laparotomy or both. GPEHR has been shown to be amenable to laparoscopic approach with low morbidity and mortality. We presented the outcome of over 200 cases of laparoscopic GPEHR (LGPEHR) with long-term follow- up over 20 years at DDW 2022. We have been performing robotic-assisted laparoscopic giant paraesophageal hernia repair (RAL-GPEHR) since 2018 and present our results. Methods We did a retrospective analysis of prospectively collected data of RAL- GPEHR using the DaVinci Xi between December 2018 and March 2024. All operating data are electronically recorded automatically by DaVinci Xi system for each surgeon/console user. Demographic data, clinical presentation, pre-operative assessment, and testing including haemoglobin (Hb), respiratory function {Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1)} as well as quality-of-life (QoL) with SF-36 questioners (including general health, physical, emotional, and social components), length of hospital stay (LOS), morbidity, mortality and follow up outcomes (Clinical, Hb, radiological, respiratory and QoL) were recorded. Results Twenty patients underwent RAL-GPEHR with 15(75%) having crural repair plus gastropexy and 5(25%) patients having additional Toupet fundoplication. Fourteen (70%) were females. Data is presented in Table 1. Presenting symptoms were dyspnoea, reflux, post-prandial pain, and dysphagia with 7(35%) anaemic. Eight (40%) were ASA III and 12(60%) ASA II. Thirteen (65%) were Type III-GPEH, 4(20%)-Type IV, one-Type II (5%) and 2(10%) recurrent GPEH. Blood loss was minimal with no intra-operative complications or conversions to open. One (5%) had post-operative chest infection. Symptoms improved in all post-operatively with improvement of Hb, FVC, FEV1 and QoL. Radiological recurrence occurred in one (5%) but remains asymptomatic. Conclusions This report represents our initial experience of a small number of patients undergoing RAL-GPEHR which has proved to be feasible and safe. A long-term follow- up with a large series of patients is required to compare long-term outcomes especially symptomatic recurrences and QoL.

811. POOLED 1-YEAR SAFETY AND QUALITY-OF-LIFE DATA AFTER REFLUXSTOP SURGERY AT TWO LARGE HOSPITALS IN SWITZERLAND: A RETROSPECTIVE CHART ANALYSIS

Abstract Background The standards of care in reflux disease management are proton pump inhibitor (PPI) therapy and conventional antireflux surgery, however, both options carry the caveats of medication irresponsiveness and troublesome postoperative sequelae, respectively. More specifically, PPIs respond inadequately in up to 40% of cases and Nissen fundoplication is associated with postoperative dysphagia in a significant proportion of patients. RefluxStop is an innovative technology that was adopted at our two respective institutions following promising safety and effectiveness data from its CE mark trial. We present the pooled safety and quality-of-life data of our 1-year experience with RefluxStop surgery. Methods Between September 2018 and August 2023, RefluxStop surgery was performed on 121 patients as part of routine clinical care at two hospitals, both of which are high-volume centers for antireflux surgery. The procedure involves crural repair with hiatal hernia reduction, reconstruction of the flap valve and angle of His, narrow esophagogastric (90-110°) plication, and device implantation in an external pouch on the gastric fundus (Figure 1). A retrospective chart analysis was conducted to document perioperative adverse events (AEs) and quality-of-life improvements via Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) score. Higher GERD-HRQL scores are indicative of more severe disease. Results Baseline patient characteristics included mean age 54.7 years, female sex (52.9%), body mass index 27.2±4.1 kg/m2, large hiatal hernia >3 cm (46.3%) of median (IQR) size 3 (2-5) cm, abnormal esophageal motility (60.3%), and Barrett’s esophagus (27.3%). At 1-year follow-up, patients experienced a median (IQR) reduction of 90.5% (81.4-100%) in total GERD-HRQL score. Intraoperative AEs included conversion to laparotomy for adhesiolysis with bleeding (n=1), bleeding short gastric arteries leading to return to the operating room the next day (n=1), and esophageal perforation repaired intraoperatively (n=1). Postoperative AEs are summarized in Table 1. Conclusion The results of this pooled retrospective chart analysis support the promising early data of the RefluxStop CE mark trial. Few and predictable AEs occurred during the study period while significant improvements in quality of life were observed, as evidenced by 90.5% (81.4-100%) reductions in GERD-HRQL score. Notably, this pooled cohort of patients was comprised of substantial proportions of difficult-to-treat patients (i.e., abnormal esophageal motility in 60.3%, large hiatal hernia >3 cm in 46.3%), providing evidence for wider implementation of RefluxStop surgery in real-world settings. Additional evaluation is required to further delineate the role of this promising innovative antireflux surgery.

Dynamics of hiatal hernia recurrence: how important is a composite crural repair?

Hiatal hernia recurrence rates vary widely. The true causes of recurrences are not fully understood but likely multifactorial. Surgical approaches and techniques have evolved over time to try and reduce recurrence rates after hiatal hernia repair. Our objective is to provide a current review on the physiology of hiatal hernias and the importance of a composite crural repair on hiatal hernia recurrence rates; more specifically, for this review, a composite repair is defined as a repair requiring more than primary closure of the crura. A recent review of the literature was conducted to identify studies reporting on hiatal hernia pathophysiology, stress, and tension, as well as the role of composite repair. There is a paucity of studies focusing on the pathophysiology of hiatal hernias and recurrence rates. Articles that report on the pathophysiology of the hiatus were found to have alterations of the extracellular matrix, collagen composition, changes in metalloproteinases (MMPs), and differences in genetic composition. The role of composite repair on reducing recurrence rates is not well studied. Hiatal hernias remain a complex problem with no ideal surgical technique. It is likely that the pathophysiology of hiatal hernias is multifactorial, and more studies need to be done to better understand the potential underlying mechanisms for hiatal hernias so this may also further identify the ideal surgical repair.

Foregut Erosion Related to Biomedical Implants: A Scoping Review.

Introduction: Biomedical devices implanted transabdominally have gained popularity over the past 50 years in the treatment of gastroesophageal reflux disease, paraesophageal hiatal hernia, and morbid obesity. Device-related foregut erosions (FEs) represent a challenging event that demands special attention owing to the potential of severe postoperative complications and death. Purpose: The aim was to provide an overview of full-thickness foregut injury leading to erosion associated with four types of biomedical devices. Methods: The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). PubMed, EMBASE, and Web of Science databases were queried until December 31, 2023. Eligible studies included all articles reporting data, management, and outcomes on device-related FE. Results: Overall, 132 articless were included for a total of 1292 patients suffering from device-related FE. Four different devices were included: the Angelchik antireflux prosthesis (AAP) (n = 25), nonabsorbable mesh for crural repair (n = 60), adjustable gastric banding (n = 1156), and magnetic sphincter augmentation device (n = 51). The elapsed time from device implant to erosion ranged from 1 to 480 months. Most commonly reported symptoms were dysphagia and epigastric pain, while acute presentation was reported rarely and mainly for gastric banding. The technique for device removal evolved from more invasive open approaches toward minimally invasive and endoscopic techniques. Esophagectomy and gastrectomy were mostly reported for nonabsorbable mesh FE. Overall mortality was .17%. Conclusions: Device-related FE is rare but may occur many years after AAP, nonabsorbable mesh, adjustable gastric banding, and magnetic sphincter augmentation implant. FE-related mortality is infrequent, however, increased postoperative morbidity and the need for esophagogastric resection were observed for nonabsorbable mesh-reinforced cruroplasty.

PHASIX™ ST MESH FOR CRURAL REINFORCEMENT DURING GIANT HIATAL HERNIA REPAIR: PRESENTATION OF SURGICAL TECHNIQUE

Abstract Aim Crural mesh reinforcement during large hiatal hernia repair has been advocated to defend against early recurrences. However, the optimal mesh material and configuration remain in question. This study presents the rationale and surgical technique for crural repair augmentation using Phasix™ ST Mesh. Methods We present a case of a giant hiatal hernia and outline the rationale and surgical technique for using Phasix™ ST Mesh in the repair. Results A 72-year-old man presented with a giant type IV hiatal hernia. A massive mediastinal protrusion of intra-abdominal fat and viscera, and an associated crucial cardiorespiratory compromise were noted. A preoperative CT scan revealed a widened hiatus measuring 9.2 × 7.6 cm. The patient underwent laparoscopic hiatal hernia repair and Nissen fundoplication. During the procedure, following visceral reduction and hernia sac dissection and excision, a widened round hiatus and significantly thinned crura were found. To reinforce the primary crural suturing, two strips of Phasix™ ST Mesh, each measuring 1.5 × 4 cm, were used, and a U-shaped mesh was placed onlay to augment the repair. The procedure lasted 214 minutes, and the patient was discharged on the 3rd postoperative day without complications. Conclusions The application of Phasix™ ST Mesh in the repair of giant hiatal hernias offers the dual benefits of reconstructing the original anatomy and reinforcing the hiatus, while avoiding the implantation of permanent foreign material around the esophagus.

Does crural repair with biosynthetic mesh improve outcomes of revisional surgery for recurrent hiatal hernia?

BackgroundLaparoscopic revisional surgery for recurrent hiatal hernia (HH) is technically demanding. Re-recurrences are common and esophageal hiatus mesh reinforcement might improve durability of the repair, thus minimizing the risk of re-herniation.PurposeAssess safety and effectiveness of simple suture repair (no mesh group) vs. crural augmentation with a biosynthetic absorbable mesh (mesh group) in patients with recurrent HH.MethodsObservational retrospective study from September 2012 to December 2022. Only patients undergoing redo surgery for previous failures of hiatal hernia repair were enrolled. Surgical failure was defined as symptomatic recurrent HH with > 2 cm of gastric tissue above the diaphragmatic impression at upper gastrointestinal endoscopy and/or swallow study. Gastro-Esophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) and Short Form-36 (SF-36) questionnaires were used to assess and preoperative and postoperative symptoms and quality of life.ResultsOne hundred four patients were included. Overall, 60 patients (57.7%) underwent mesh-reinforced cruroplasty, whereas 44 (42.3%) underwent simple suture cruroplasty. Mesh and no mesh groups had similar baseline demographics, symptoms, prevalence of esophagitis and Barrett’s esophagus, and HH size. A composite crural repair was most commonly performed in the mesh group (38.3% vs. 20.5%; p = 0.07). In addition to cruroplasty, most patients (91%) underwent a Toupet fundoplication. The 90-day postoperative complication rate was 8.6%, and there was no mortality. Recurrent HH was diagnosed in 21 patients (20.2%) with a clinical trend toward reduced incidence in the mesh group (16.7% vs. 25%; p = 0.06). Compared to baseline, there was a statistically significant improvement of median GERD-HRQL score (p < 0.01) and all SF-36 items (p < 0.01).ConclusionsLaparoscopic revisional surgery for recurrent HH is safe and effective. Selective use of biosynthetic mesh may protect from early recurrence and has the potential to reduce re-herniation in the long-term.

Rationale and Trial Protocol for a Double-Blinded Randomized Controlled Trial to assess the Impact of a Concomitant Crural Repair during Laparoscopic Sleeve Gastrectomy in Patients with a Lax Gastroesophageal Junction without Frank Hiatal Hernia (REPAIR trial protocol).

Laparoscopic sleeve gastrectomy (LSG) is associated with postoperative gastroesophageal reflux disease (GERD) and erosive esophagitis (EE). The role of crural repair during LSG is still controversial. The preoperative laxity of the gastroesophageal junction (GEJ), graded by the Hill's classification, is more predictive for postoperative GERD and EE after LSG than the presence of a hiatal hernia seen on endoscopy. Thus, the authors hypothesize that a concomitant crural repair in a specific subgroup of patients with a lax GEJ (Hill's III) may reduce the incidence of postoperative GERD and EE. A double-blinded, randomized controlled trial of patients with Hill's III GEJ undergoing LSG will be randomized to a concomitant crural repair (experimental) versus LSG alone (control). Primary outcome measures will be presence of EE at 1-year. Secondary outcome measures will include proton pump inhibitor use, postoperative complications, operative time, blood loss, quality of life, GERD and gastrointestinal symptoms. Conflicting crural repair results may be explained by differences in preoperative GEJ laxity. Patients with a frank hiatal hernia and patulous GEJ (Hill's IV) have a very high, while patients with an apposed GEJ (Hill's I, Hill's II) have a low incidence of postoperative GERD and EE respectively. Thus, the authors hypothesize that patients with a lax GEJ without frank hiatal hernia (Hill's III), might benefit from a crural repair. This study results can potentially highlight the clinical importance of preoperative endoscopic evaluation of the GEJ in all patients planned for LSG, to determine which subgroup patients may benefit from a crural repair. (Clinicaltrials.gov: NCT05330910, Registered 15-April-2022).

The value of "diaphragmatic relaxing incision" for the durability of the crural repair in patients with paraesophageal hernia: a double blind randomized clinical trial.

Surgical repair of paraesophageal hernias (PEHs) is burdened with high recurrence rates, and hitherto various techniques explored to enforce the traditional crural repair have not been successful. The hiatal reconstruction in PEH is exposed to significant tension, which may be minimized by adding a diaphragmatic relaxing incision to enhance the durability of the crural repair. All individuals undergoing elective laparoscopic repair of a large PEH, irrespective of age, were considered eligible. PEHs were classified into types II-IV. The preoperative work-up program included multidetector computed tomography and symptom assessment questionnaires, which will be repeated during the postoperative follow-up. Patients were randomly divided into a control group with crural repair alone and an intervention group with the addition of a left-sided diaphragmatic relaxing incision at the edge of the upper pole of the spleen. The diaphragmatic defect was then covered by a synthetic mesh. The primary endpoint of this trial was the rate of anatomical PEH recurrence at 1 year. Secondary endpoints included symptomatic gastroesophageal reflux disease, dysphagia, odynophagia, gas bloat, regurgitation, chest pain, abdominal pain, nausea, vomiting, postprandial pain, cardiovascular and pulmonary symptoms, and patient satisfaction in the immediate postoperative course (3 months) and at 1 year. Postoperative complications, morbidity, and disease burden were recorded for each patient. This was a double-blind study, meaning that the operation report was filed in a locked archive to keep the patient, staff, and clinical assessors blinded to the study group allocation. Blinding must not be broken during the follow-up unless required by any emergencies in the clinical management of the patient. Likewise, the patients must not be informed about the details of the operation. ClinicalTrials.gov, identification number NCT04179578.

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery

Antireflux surgery is an effective treatment of gastroesophageal reflux disease (GERD), but the durability of concomitant hiatal hernia repair remains challenging. Previous research reported that the use of a mesh-reinforced, tension-free technique was associated with more dysphagia for solid foods after 3 years without reducing hiatal hernia recurrence rates compared with crural sutures alone, but the long-term effects of this technique have not been assessed. To assess the long-term anatomical and functional outcomes of using a mesh for hiatal hernia repair in patients with GERD. A double-blind, randomized clinical trial was performed at a single center (Ersta Hospital, Stockholm, Sweden) from January 11, 2006, to December 1, 2010. A total of 159 patients were recruited and randomly assigned. Data for the current analysis were collected from September 1, 2021, to March 31, 2022. All analyses were conducted with the intention-to-treat population. Closure of the diaphragmatic hiatus with crural sutures alone vs a tension-free technique using a nonabsorbable polytetrafluoroethylene mesh (Bard CruraSoft). The primary outcome was radiologically verified recurrent hiatal hernia after more than 10 years. Secondary outcomes were dysphagia scores (ranging from 1 to 4, with 1 indicating no episodes of dysphagia and 4 indicating more than 3 episodes of dysphagia per day) for solid and liquid foods, generic 36-Item Short Form Health Survey and disease-specific Gastrointestinal Symptom Rating Scale symptom assessment scores, proton pump inhibitor consumption, and reoperation rates. Intergroup comparisons of parametric data were performed using t tests; for nonparametric data, Mann-Whitney U, χ2, or Fisher exact tests were used. For intragroup comparisons vs the baseline at follow-up times, the Friedman test was used, and post hoc analysis was performed using Wilcoxon matched pairs. Of 145 available patients, follow-up data were obtained from 103 (response rate 71%; mean [SD] age at follow-up, 65 [11.3] years; 55 [53%] female), with 53 initially randomly assigned to mesh reinforcement, and 50 to crural suture alone. The mean (SD) follow-up time was 13 (1.1) years. The verified radiologic hiatal hernia recurrence rates were 11 of 29 (38%) in the mesh group vs 11 of 35 (31%) in the suture group (P = .61). However, 13 years postoperatively, mean (SD) dysphagia scores for solids remained significantly higher in the mesh group (mean [SD], 1.9 [0.7] vs 1.6 [0.9]; P = .01). Findings from this long-term follow-up of a randomized clinical trial suggest that tension-free crural repair with nonabsorbable mesh does not reduce the incidence of hiatal hernia recurrence 13 years postoperatively. This finding combined with maintained higher dysphagia scores does not support the routine use of tension-free polytetrafluoroethylene mesh closure in laparoscopic hiatal hernia repair for treatment of GERD. ClinicalTrials.gov Identifier: NCT05069493.

Technical Considerations and Approach to Redo Foregut Surgery.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redohiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissectionto free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

412. INTRAOPERATIVE APPLICATION OF ENDOFLIP FOR THE REPAIR OF HIATUS HERNIA AND FUNDOPLICATION

Abstract https://drive.google.com/file/d/1N3wVZ2UvO3eGBScjHMwtcJiCqfU0wUp1/view Background There is no objective measurement during repair of hiatus hernia and fundoplication intraoperatively. Whether the patient needs Nissen, Toupet or other fundoplication requires individual consideration. If the wrap repaired too tight, patient will develop dysphagia after surgery. If the wrap fold too loose, then the patient may experinced persistent reflux symptoms. This video demonstrate the application of EndoFlip intraoperatively to objectively measure the distensibility of the lower esophageal sphincter. Method Patient underwent laparoscopic hiatus hernia and fundoplication after symptoms assessment and confirmation of diagnosis. Intraoperatively, EndFlip probe was inserted and distensibility were measured as pre-dissection, post abdominal resection, post crural repair and after fundoplication. Tightness of fundoplication is adjusted aming at distenisbiliary index ranged 2–4. Results This study demonstrate the intraoperative aspproach for using EndoFlip as the tool to adjust the appropriate tightness on creating the wrap. Fpr this particular patient, before crus dissection, the distensibility index (DI) was 4.5, after crural dissection, DI was 5.5. After crural repair and Toupet fundoplication, the DI was 2.5. Post-operatively, patient had all the proton pump inhibitor stopped and enjoying good quality of life. Conclusion Objective intraoperative measurement during fundoplication is now available. Appropriate tightness of the wrap can be adjusted to avoidf post operative dysphagia or persistent reflus.

397. LEFT PILLAR PINCHING TECHNIQUE FOR MINIMALLY INVASIVE REPAIR OF PARA-CONDUIT HERNIA

Abstract Surgical repair of the para-conduit hernia provides an increasing challenge in the era of minimally invasive oesophagectomy. The key principles are preservation of the gastric conduit and its right gatro epiploic vascular arcade, and durable closure of the defect. Of various methods, posterior crural repair is difficult without mobilising and risking and kinking the conduit, while anterior repair of a big defect requires the adjunct of a mesh which carries its own risks of infection or erosion. There is no consensus on the appropriate surgical technique. We propose that the Left pillar of the hiatus be pinched to provide an effective repair. This is safe as dissection and suturing is well away from the conduit and arcade. We find the left pillar to be adequately mobile to allow repair, and the sutures sit in the tendinous portion of the left hemi diaphragm to provide durability. We provide 2 videos to describe the key steps in this technique and demonstrate that this technique is effective in both small and large defects, and acute and chronic para-conduit hernia. Link: https://1drv.ms/v/s!Anu-cyBTuGbsgbxtX8aLf2P1YEPl9g?e=fXz7Pm. Please contact me, shantjog@gmail.com if this link does not work and I will explore an alternative method to share the video. Many thanks.

Impact of laparoscopic repair on type III/IV giant paraesophageal hernias: a single-center experience

PurposeGiant paraesophageal hernia (GPEH) is a challenging problem for surgeons because of its high recurrence rate. This study was conducted to compare the outcomes in type IV vs. type III GPEHs after laparoscopic repair. Other outcomes included peri-operative morbidity and long-term quality of life.MethodsA retrospective analysis of 130 GPEH patients in a period between 2010 and 2019 underwent a tailored laparoscopic repair in our tertiary center with a minimum follow-up of 48 months. Operative steps included hernial sac excision, crural repair, relaxing incisions, and mesh cruroplasty with special indications.ResultsThe study enrolled 90 patients with type III and 40 patients with type IV GPEH. Type IV GPEH patients were older, more fragile, and scored worse on ASA classification, aside from having a more challenging surgical technique (wider crura, weaker muscles, increased need for release incisions, and mesh cruroplasty).Type IV GPEHs had a prolonged operative durations, and a higher conversion rate. Additionally, the same group showed increased morbidity, mortality, and re-operation rates. With a mean follow-up of 65 months (range 48–150 months), the incidence of recurrence was 20.7%, with an increased incidence in type IV GPEH (37.5% vs. 13.33% in type III GPEH). Type IV GPEH, low pre-operative albumin, larger crural defect, and low surgeon experience were significant risk factors for recurrence after laparoscopic repair of GPEH.ConclusionType IV GPEH has a higher peri-operative morbidity and recurrence rate; so, a more tailored laparoscopic repair with a high surgeon experience is needed.

ThTP2.11 Three-year follow up outcomes in mesh-augmented vs sutured cruroplasty in giant hiatal hernia repair

Abstract Aims There is no consensus for indications on mesh-augmentation of crural repair in hiatus hernia. We evaluated outcomes following mesh-augmented versus suture repair of giant hiatus hernia. Methods Giant hiatus hernia was defined as a hernia containing at least 30% of the stomach in the thorax. We undertook a retrospective analysis of records for patients undergoing surgical repair of hiatus hernia in a tertiary centre between 2016 and 2019, with a minimum follow up of three years. Patients were identified using clinical coding. Pre-operative investigations (OGD, barium swallow, CT) and operative findings were used to identify those patients with giant hiatus hernias. Outcomes assessed included morbidity, recurrence and revisional surgery. Results 58 patients of median age 72 (27-90) underwent repair of a giant hiatus hernia. 56 (97%) were performed laparoscopically (1 conversion, 1 open). All were primary procedures, 50 elective and 8 emergency. 20 had mesh-augmented suture repair (19 BIO-A, 1 Permacol) and 38 had primary suture repair alone. 26 (44.8%) had additional fundoplication. By three years post-surgery 14/58 (24%) recurrent hiatus hernias were identified on further investigation, similar in both groups (5/20 vs 9/38). Symptomatic revisional surgery was undertaken in 2/20 (10%) mesh-augmented and 2/38 (5%) suture only repairs. 30-day mortality was 0%. Morbidity (Clavien-Dindo 3+) was recorded in 5 patients (8.6%). Conclusion Giant hiatal hernia repair complication and recurrence rates were comparable to published studies. Those patients with recurrence following mesh-augmented repair were more likely to require revision surgery. However mesh may be used in cruroplasty for perceived weaker or wider crura.

Hiatal hernia recurrences after laparoscopic surgery: exploring the optimal technique.

The recurrence rate of hiatal hernia (HH) after laparoscopic surgery with crural repair and Nissen or Toupet fundoplication is high (< 25-42%). HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS) or mesh placement but the effect in the long-term (> 1year) is still unclear. We determined the recurrence rate of HH after surgery and established whether the use of reinforcement techniques could reduce long-term recurrence rates. In this retrospective cohort study patients were included if they underwent a laparoscopic fundoplication in this hospital between 2012 and 2019. HH was measured with computed tomography and baseline patient characteristics and surgical details were collected. Primary outcomes were recurrence of symptoms and re-intervention, secondary outcome was effect of surgical reinforcement techniques. Statistical analyses comprised chi-square tests, Mann-Whitney U tests and uni- and multivariable logistic regression analyses. In total, 307 patients were included, 206 women and 101 men. During primary surgery, 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients and mesh in 17 patients. After primary surgery, recurrence of HH was diagnostically confirmed in 64 patients (20.8%). Use of VMS during primary surgery was significantly associated with fewer recurrences (OR = 0.34, p = 0.048), corrected for confounding factors. Secondary surgery was performed in 54 patients (17.6%) and tertiary surgery in five patients (1.6%). Mesh and VMS were used more during secondary and tertiary surgery. The recurrence rate among HH patients in this cohort study was 20.8% with a mean follow-up time of 6years. Secondary surgery was performed in 17.6% of the patients. In future, the use of VMS might lead to fewer recurrences after primary laparoscopic repair of HH.

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

Summary Background The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force. Methods An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence. Results Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia. Conclusion A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.

Is systematic formal crural repair mandatory at the time of magnetic sphincter augmentation implantation?

Laparoscopic placement of the LINX Magnetic Sphincter Augmentation (MSA) device has become an accepted alternative to fundoplication in appropriate patients. Initial studies of MSA targeted to patients with 'early' disease allowed for the most minimal dissection of the esophagus to place the device, without hiatal dissection or repair (NoHHR), in patients with no or minimal hernia findings at surgery. Subsequent studies have compared systematic formal hiatal dissection and repair (Formal HHR) with the original minimal dissection technique. Review of published literature on MSA includes discussion on treatment of hiatal hernia at the time of implantation, accompanying the review of the physiology of the crural diaphragm. Formal hiatal hernia repair at the time of MSA implantation results in better control of reflux with less dysphagia and risk of postoperative hernia than NoHHR, regardless of the presence or size of hiatal hernia. Systematic crural repair should accompany any MSA implantation regardless of the presence or size of hiatal hernia.