Hiatal Repair Research Articles

Fibrin Sealant (Tissucol) for the Fixation of Hiatal Mesh in the Repair of Giant Paraesophageal Hernia

The use of hiatal meshes for the repair of giant paraesophageal hernias (GPH) is associated with a significantly decreased rate of recurrences compared with mesh free techniques. Many surgeons refrain from mesh implantation at the gastroesophageal junction owing to reported complications, such as mesh migration, strictures, and risks of tack or suture placement. This case report presents the laparoscopic application of a titanium-coated mesh (TiSure, GfE, Germany) designated for hiatal repair, with fibrin sealant fixation (Tissucol, Baxter, Austria) in a patient with GPH. A patient (male, 59 y) presented at our outpatient department with a 3-year history of epigastric pain and decreasing lung capacity. A GPH with an intrathoracic upside-down stomach had already been radiologically diagnosed 3 years before admission. In elective laparoscopy, the stomach was repositioned and the crura of the diaphragm were approximated with nonresorbable sutures. The defect was reinforced with a preshaped titanium-coated mesh and fibrin sealant (2 mL) applied with a 45 degree angled tip laparoscopic spraying device. No perforating fixation device was used for mesh fixation itself. The patient was discharged on the seventeenth postoperative (postOP) day. The clinical follow-up included the assessment of postOP pain with a visual analog score and a confirmative computed tomography scan 6 months after surgery. The patient has fully recovered, showing no recurrence or adverse effects 1 year postOP. Based on previous good results from own experimental trials, the mesh sealing approach in hiatal hernia repair was performed clinically, yielding an excellent result in this case. Multicenter trials to assess the full impact of FS mesh fixation in combination with macroporous hiatal meshes seem mandatory.

HP25P SLEEVE GASTRECTOMY FOR LARGE PARAOESOPHAGEAL HIATUS HERNIAS

Purpose: The initial experience with laparoscopic partial sleeve gastrectomy to excise the herniated stomach to treat symptomatic, large para-oesophageal hernias is reported. Methodology: The laparoscopic repair consisted of 1 Reduction of the herniated stomach from the chest 2 Partial sleeve gastrectomy 3 Repair of hiatal defect with or without mesh 4 Gastropexy. Results: Since May 2006, 11 patients had surgery for large para-oesophageal hernias. All suffered with post prandial discomfort and vomiting preoperatively. One patient underwent open Nissen fundoplication instead of laparoscopic sleeve gastrectomy because of intraoperative haemorrhage. Ten patients had a partial sleeve gastrectomy. Hiatal repair included the use of mesh in 7 out of the 10 patients and 9 of the patients had an anterior gastropexy. The only patient not to have a gastropexy suffered a symptomatic recurrence 13 days after surgery. Five out of 10 patients had complete relief of symptoms after surgery. Four out of ten patients were symptomatic with reflux. One patient continues to have post prandial discomfort and vomiting intermittently, due to a “twist” of the gastric tube. Observations: In this series, laparoscopic partial sleeve gastrectomy for large para-oesophageal hernia repair was associated with a recurrence rate of 1 in 10. Anterior gastropexy may be important in preventing recurrence. Relief of preoperative symptoms was achieved in 9 out of 10 patients but 4 of these 9 report reflux symptoms.

Omission of the calibration bougie in laparoscopic repair of paraesophageal hernia

The use of an intraesophageal bougie has traditionally been an integral step in the repair of large hiatal hernia and fundoplication. Typically, the bougie is passed by the anesthesiologist or a member of the surgical team into the stomach to enable calibration of the hiatal repair and fundoplication. An inherent risk of esophagogastric perforation is associated with this maneuver. The authors report their experience comparing symptomatic outcomes for patients who have had a large hiatus hernia repaired with and without the use of a calibration bougie. Data were collected prospectively for 28 consecutive patients undergoing elective laparoscopic repair of a paraesophageal hernia. A bougie was used in the first 14 patients. In the next 14 patients, the use of a bougie was omitted. Symptom and quality-of-life data were collected preoperatively and 6 months postoperatively for all the patients. All the patients were satisfied with their symptomatic outcome, as reflected in their postoperative quality-of-life scores. No patients required dilation for postoperative dysphagia. There was no difference in postoperative dysphagia scores between the two groups. The current series of consecutively performed laparoscopic paraesophageal hernia repairs showed no benefit in terms of symptomatic outcome associated with the use of an intraesophageal bougie. Currently, the authors' standard practice is to perform laparoscopic repair of the paraesophageal hernia and fundoplication without the aid of a calibration bougie.

Erosion of a Composite PTFE/ePTFE Mesh After Hiatal Hernia Repair

Primary repair of large hiatal defects is associated with higher than acceptable recurrence rates. This has led to the increased use of fascial prostheses for reinforcement of the hiatal repair. We report a case of intraluminal mesh erosion after repair of a recurrent paraesophageal hernia with a composite polytetrafluoroethylene/expanded polytetrafluoroethylene prosthesis in an 80-year-old woman. Mesh erosion is a rarely reported complication after hiatal hernia repair, and because many cases will go unreported, their true incidence is unknown. Besides the durability of mesh repair, the ongoing clinical trials investigating laparoscopic correction of hiatal hernias should also focus on the risk of complications associated with the use of prosthetic materials and the mode of fixation.

Robotic Repair of Congenital Paraesophageal Hiatal Hernia

Congenital paraesophageal hiatal hernias are rare and can be associated with gastric incarceration, volvulus,mucosal ulceration, and anemia. Primary repair of the hernia and fundoplication are recommended. In this paper,we report a case of a 3-year-old child with abdominal pain who was noted to have a paraesophageal hiatal hernia with partial gastric volvulus. A 5 mm robot platform was utilized to facilitate hernia sac dissection,hiatal repair, and fundoplication.

Evaluation of lightweight titanium-coated polypropylene mesh (TiMesh) for laparoscopic repair of large hiatal hernias

The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison with primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to evaluate a lightweight polypropylene mesh (TiMesh) repair of hiatal hernias with particular reference to intraluminal erosion. Data were collected prospectively on 18 consecutive patients undergoing elective laparoscopic repair of a large hiatal hernia with the use of TiMesh between November 2004 and December 2005. Quality of life and symptom analysis was performed using QOLRAD questionnaires preoperatively and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed preoperatively and 2 years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of mesh-related complications. All operations were completed laparoscopically. There was no 30-day mortality and median hospital stay was 2.8 days (range 2-13 days). Complications occurred in two patients (11%), both of whom were treated without residual disability. Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD 5.79, p < 0.001). There was no difference between pre- and postoperative dysphagia scores. No signs of stricture formation or prosthetic erosion were identified during endoscopic follow-up. One patient had a small (2 cm) sliding hiatal hernia demonstrated by barium studies, which was asymptomatic. Laparoscopic reinforcement of primary hiatal closure with TiMesh leads to a durable repair in patients with large hiatal hernias. Endoscopic follow-up did not show any signs of mesh-related complications after prosthetic reinforcement of the crural repair. Our preliminary results suggest that it is safe to proceed with this lightweight polypropylene mesh for reinforcement of the hiatal repair.

Consideration of Mesh-Related Complications

If ‘better is the enemy of good’, then both sides of the controversy for the use of mesh in hiatus hernia repair have missed the point.1 The argument rests on whether what we do is already good enough. Kelty and Falk state that mesh repair would only be necessary in the 10–30% of patients who recur; this implies that all recurrences are symptomatic. This is not the case in our unit — in 322 consecutive patients who underwent para-oesophageal hernia repair without mesh, only eight patients (2.5%) required re-operation for symptomatic recurrence. Although the recurrent hernia rate for our series probably lies between 10–30%, it is symptoms that matter and 303 patients (94%) reported satisfaction with their surgery. As a specialist unit performing re-operations on mesh-related complications from other units, we strongly advise that informed consent for elective mesh repair includes future oesophagectomy should problems occur. Failure to do so will eventually result in litigation and this fact alone should deter surgeons from ‘banging a mesh in’. In contrast, re-operating on non-mesh cases, although challenging, is usually straightforward. In summary, we believe that non-mesh, para-oesophageal, hiatal repair is not far off ‘good enough’ and as Smith alludes – it will only be known through randomised evaluation of whether the placement of mesh is ‘better’.

The Rossetti—Nissen fundoplication — effective in managing gastro-oesophageal reflux disease

The report herein details a prospective audit of a unit's eight-year experience of the Rossetti-Nissen fundoplication using a predominantly laparoscopic technique, selective hiatal repair, no bougie and a standardised protocol of pre- and post-operative functional endoscopic and symptom assessment. Three hundred and seventy-eight patients underwent the Rossetti-Nissen fundoplication. All patients had documented data on endoscopy, health related quality of life (HR-QoL), surgical details and complications pre-operatively and at six months post-operatively. Repeat physiological testing was performed at six months. At a median follow-up of six (range 3-13) months there was improved symptom scoring and HR-QoL after fundoplication with an 89% patient satisfaction rate. Ninety-five patients (25%) reported some early dysphagia, and 91 of these reported the outcome of surgery to be excellent or good. Thirty-eight patients (10%) had recurrent heartburn and 28 (7%) were back on medication at six months post-operatively. At follow-up pH study at a median of six months, 89% of patients had normalised acid reflux scores. Rossetti-Nissen fundoplication, with no use of an oesophageal bougie and no division of short gastric vessels, is an effective procedure giving 89% patient satisfaction and significant improvement in QoL parameters and physiological measurements.

Laparoscopic Nissen fundoplication with anterior versus posterior hiatal repair: long-term results of a randomized trial

Background Postoperative dysphagia in patients after Nissen fundoplication might be related to the technique used for the closure of the esophageal hiatus. Methods A total of 102 patients with gastroesophageal reflux were randomized to undergo laparoscopic Nissen fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. Results Clinical data at 5 years after surgery were available for 96% of patients enrolled in the trial. There was no significant difference between the 2 techniques for symptoms of dysphagia at the 5-year follow-up evaluation, although more patients who underwent posterior hiatal repair underwent further surgery for dysphagia-related symptoms (8 vs 2). Better control of heartburn was achieved in patients in the anterior hiatal repair group. Patients from both groups were equally satisfied with the overall outcome after surgery. Conclusions At the 5-year follow-up evaluation, there was no significant difference in dysphagia between anterior closure and posterior hiatal repair.

Evaluation of DualMesh for repair of large hiatus hernia in a porcine model

Prosthetic fascial grafts are frequently used for augmentation of cruroplasty in large hiatus hernia repair to decrease the chances of recurrence. Potential complications such as intraluminal erosion may be related to the constant movement of mesh and diaphragm over the outer surface of the esophagus. This study aimed to evaluate DualMesh for repair of large hiatal defects in a porcine model. In this study, 18 Landrace x large white x Duroc crossbred pigs underwent either primary hiatal repair or tension-free prosthetic repair using DualMesh (80 x 50 mm or 80 x 100 mm). The animals were killed at 3 or 28 weeks for macroscopic and histologic evaluation of the hiatal region and gastroesophageal junction. All grafts had become encapsulated at 28 weeks, and the majority had filmy adhesions only to the visceral aspect. In all models, the esophagus moved freely over the cut edge of the prosthesis. No signs of intraluminal erosion were documented. At histologic examination, significant ingrowth was noted on the porous side of the mesh, whereas no defined mesothelial layer was identified on the capsule of the nonporous side. In this animal model of large hiatus hernia repair, DualMesh showed optimal characteristics in terms of host tissue incorporation on the porous side and absence of adhesions on the visceral side of the prosthesis. The absence of adhesions and intraluminal erosion in this study may provide reassurance to surgeons using mesh at the hiatus.

Complications of PTFE Mesh at the Diaphragmatic Hiatus

Paraesophageal hernia repair has been associated with a recurrence rate of up to 42%. Thus, in the last decade, there has been increasing interest in the use of mesh reinforcement of the hiatal repair. Polytetrafluoroethylene (PTFE) is one of the materials that have been used for this purpose, as it is thought to induce minimal tissue reaction. We report two cases in which complications specific to the use of PTFE mesh in this location developed over time. In the first patient, a gastrectomy was required to remove a large PTFE mesh which had eroded into the esophagogastric junction and gastric cardia. The second patient experienced severe dysphagia resulting from a stricture caused by the implant, requiring removal of the mesh. Although such complications have only rarely been reported, the severity and consequences of these incidents, as reported in the literature and in light of our observations, suggest that an alternative to PTFE should be considered for crural reinforcement during paraesophageal hernia repair.

Objective Follow‐up after Laparoscopic Repair of Large Type III Hiatal Hernia. Assessment of Safety and Durability

Symptomatic results of laparoscopic repair of large type III hiatal hernias, with/without prosthetic mesh, are often excellent; however, a high recurrence rate is detected when objective radiological/endoscopic follow-up is performed. The use of mesh may reduce the incidence of postoperative hernia recurrence or wrap migration in the chest. We retrospectively studied 54 patients (10 men, 44 women; median: age 64.5 years) with a diagnosis of large type III hiatal hernia (>1/3 stomach in the chest on x-ray) who underwent laparoscopic repair at our department from January 1992 to June 2005. Complications, recurrences, and symptomatic and objective (radiological/endoscopic) long-term outcome were evaluated. Nineteen patients had laparoscopic Nissen/Toupet fundoplication with simple suture; in 35 patients a double mesh was added. The median radiological/endoscopic follow-up was 64 months (interquartile range (IQR): 6-104) for the non-mesh group and 33 (IQR:12-61) for the mesh group (p = 0.26). Recurrences occurred in 11/54 (20%) patients: 8/19 (42.1%) without mesh and 3/35 (8.6%) with mesh (p = 0.01). The 3 recurrences in the mesh group all occurred < or =12 months postoperatively; 4/8 recurrences in the non-mesh group occurred > or =5 years after operation. On multivariate logistic regression analysis, only mesh absence significantly predicted hernia recurrence or wrap migration. Laparoscopic repair of large type III hiatal hernias is safe and effective. Short-term symptomatic results are excellent, but mid-term objective radiological/endoscopic evaluation reveals a high recurrence rate. Possible reasons for failure of a laparoscopic hiatal repair are tension or poor muscle tissue characteristics in the hiatus. The use of a mesh, either by reducing tension or reinforcing muscle at the hiatus, might be associated with a lower recurrence rate. Longer-term follow-up will be needed before definitive conclusions can be drawn, however.

Results of laparoscopic reoperation for failed antireflux surgery: does the indication for redo surgery affect the outcome?

Short and medium term outcomes from laparoscopic antireflux surgery are generally excellent. A small number of patients suffer recurrent reflux or intolerable side-effects and may require reoperation. In this paper we describe our experience of 35 laparoscopic reoperations from a single center. Data on patients undergoing antireflux surgery in our unit has been prospectively collected and includes more than 600 primary laparoscopic antireflux operations since 1993. Laparoscopic reoperations have been performed between 1996 and 2005 for patients suffering recurrent reflux, dysphagia or severe gas bloat symptomatic despite medical treatment. All patients underwent preoperative barium studies and endoscopy with selective manometry and pH studies. Symptomatic outcomes were evaluated at 6 weeks and 12 months with Visick scores. Anatomical results were assessed with barium studies at between 6 and 12 months. Thirty-five laparoscopic reoperations were performed in 20 women and 13 men (median age 56 years). Primary surgery had been performed in our unit in 27 (77%) and elsewhere in eight (23%). Median time from primary surgery was 28.5 months (5-360). Two patients underwent a second reoperation. Indication was recurrent reflux in 28 (80%), dysphagia in five (14%) and gas bloat in two (6%). Thirty-two of the 35 reoperations (91.4%) were completed laparoscopically, median operating time was 120.5 min (65-210) and median hospital stay 2 days. There was no mortality and there were only five minor complications. Twelve-month follow-up was available for 32 reoperations (91%). Overall good symptomatic outcomes were obtained in 26 (74%) Visick I or II at 6 weeks and 24 of 32 (75%) at 12 months. In reoperations for dysphagia/gas bloat there was a relative risk of 4.26 of a poor symptomatic outcome (Visick III or IV) at 12 months compared to those for recurrent reflux (P < 0.05, Fisher's exact test). Laparoscopic reoperation is feasible with low conversion rates and minimal morbidity for patients who have undergone previous abdominal or thoracic hiatal repair. Symptomatic outcomes are generally good, particularly if the indication is recurrent reflux.

Laparoscopıc Fundoplicatıon with Prosthetic Hiatal Closure

Despite the good results reported after laparoscopic fundoplication, failure is still a major problem. Hiatal disruption is one of the common patterns of anatomical failure. The aim of this study was to compare the results of suture repair of diaphragmatic crura with routine polypropylene mesh reinforcement in addition to suture repair. A total of 551 patients who underwent laparoscopic fundoplication for gastroesophageal reflux disease between March 1998 and July 2004 were included into the study. Crural closure had been performed with simple primary suture repair alone between March 1998 and July 2002 (n = 335, group I), and mesh reinforcement of the hiatal repair was performed routinely thereafter (n = 176, group II). These groups were evaluated prospectively. We observed a significantly lower rate of recurrence in group II than in group I. After a 2-year follow-up, the rate of anatomic morphologic recurrence was 6.0% in group I and 1.8% in group II. Considering the recurrence rate, there was significant statistical difference. The overall recurrence rate in our series was 4.6%. There was no correlation between the size of the hernia and recurrence. No significant difference was found between groups regarding the rate of postoperative dysphagia. We have not observed any complications related to the use of polypropylene mesh in group II. The results of this study suggest that polypropylene mesh reinforcement increases the success rate for laparoscopic hiatal hernia repair without causing an additional complication burden. We propose routine use of mesh reinforcement in laparascopic antireflux surgery.

The use of biosynthetic mesh to enhance hiatal repair at the time of redo Nissen fundoplication

Objective There are a number of reports in the literature describing the need for a redo fundoplication in patients who have previously undergone open fundoplication. However, these data are not well characterized in our current era of laparoscopic surgery. The purpose of this report is to document the management of patients requiring a redo fundoplication who originally underwent a laparoscopic Nissen fundoplication. Methods After internal review board approval, the senior surgeon performed a retrospective chart review on all patients undergoing laparoscopic fundoplication between January 2000 and April 2006. Data collected included the patient's age, sex, neurologic impairment, need for gastrostomy, time interval between the initial and redo fundoplication, operative approach for the redo fundoplication, use of a biologic patch for the redo procedure, and length of follow-up. Results Two hundred seventy-three patients underwent laparoscopic Nissen fundoplication by the senior author during this time interval. Twenty-one patients have required a redo fundoplication and repair of the enlarged hiatus after laparoscopic fundoplication. No patient has undergone a redo procedure without the development of transmigration of the fundoplication wrap. A redo operation was performed without mesh in 13 patients, of which there were 4 recurrences (31%). The other 8 cases were repaired with Surgisis (Cook, Inc, Bloomington, Ind), and none of these have recurred, with a minimum of 11 months' follow-up and a mean follow-up of 26 months. In the 4 patients requiring a second redo procedure, the enlarged esophageal hiatus was reinforced with Surgisis, and none of these cases have recurred, with a minimum of 3 years' follow-up. Conclusions Our data support the use of a biosynthetic mesh to reinforce the crural closure during the repair of iatrogenic hiatal hernias in children.

Die laparoskopische Semifundoplikation nach Dor zur Behandlung der Gastroösophagealen Refluxkrankheit

Gastroesophageal reflux disease is a major health problem in western industrial nations. Several prospective randomized studies showed the operative therapy of GERD superior to a steady medication with omeprazole regarding recurrence rate as well as rate of side effects. The today most performed 360 degrees fundoplication (Nissen-Rossetti) leads in 10-30% to a persisting postoperative dysphagia. We prefer the anterior semifundoplication by Dor. Aim of our study is to find out if our results are comparable to current literature and to open procedure. Between 1.1.03 and 30.6.05 one operator performed on 100 consecutive patients (57 female, 43 male) between 29 and 86 years of age an anterior Dor-semifundoplication with posterior hiatal repair. In 37 cases we performed a cholecystectomy simultaneously, on two patients a sigmoid resection and in one case a left pancreatic resection. 52 Patients were re-evaluated after six months (median follow up nine months). Median operation time was 71 min (30-250 min). The learning curve showed a time reduction of initially 102 to 40 min in the last 10 cases. Blood loss was between 10 and 300 ml (median 40 ml). No conversion was necessary). As intraoperative complication in one case the right pleural cavity was opened. Postoperative complications were found to be wound infection in one case and urinary tract infection in another. Postoperative stay was four days (2-19 d) and eight days respectively for patients after sigmoid resection or left pancreatic resection. After median follow up of nine months 45 of 52 re-evaluated patients (86%) were free of reflux symptoms, 47 (90%) were pleased or very pleased with the result of the operation. Four patients felt at least a reduction of preoperative symptoms. The anterior Dor semifundoplication is a technically easy and low risk procedure, which has a lower side effect rate than the 360 degrees operation and will heal 90% of the patients from their reflux disease.

Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications

Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence. A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both. Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract. The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.

Outcome of laparoscopic redo fundoplication

We have read with interest the recently published article Outcome of Laparoscopic Redo Fundoplication by Dutta et al. [2]. In this article,the authors review their experience with 28 consecutive patients who underwent laparoscopic revisional fundoplication for primary failed antireflux surgery. On the basis of objective outcome parameters such as results from 24 h of pH monitoring and esophageal manometry,this study shows that laparoscopic refundoplication can be a safe and effective procedure for patients who have failed primary antireflux surgery. A significant decrease in acid reflux and a significant increase in lower esophageal sphincter pressure was achieved for these patients. Additionally,patients showed a significant decrease in gastroesophageal reflux disease symptoms after refundoplication. The field of laparoscopic redo fundoplication is challenging. Therefore,the authors should be congratulated for their excellent results. It has been reported that objective outcome parameters improve after laparoscopic refundoplication [3,4]. However,we believe that long-term evaluation of functional outcome parameters as well as symptomatic outcome and patientrelated factors such as quality of life and patient satisfaction are needed to prove the effectiveness of laparoscopic redo fundoplication. The authors describe a mean follow-up period of 22 months,although they finally evaluated objective criteria 6 months postoperatively. Like other authors [5,6],we totally agree with Dutta et al. [2] that intrathoracic wrap herniation is the most frequent anatomic morphologic complication after laparoscopic fundoplication. Therefore,most authors recommend a sufficient hiatal closure during primary laparoscopic antireflux surgery [1]. In the current study, the authors included four patients whose morphologic cause for reoperation was postoperative wrap herniation. In this group,hiatal hernia,described as the most common cause for reherniation,was not repaired at the initial procedure. It would be interesting to know whether there have been more patients without primary hiatal repair who had no postoperative reherniation of the wrap.

Mesh in the Hiatus

To analyze the experience acquired to date on the use of prosthetic mesh to prevent recurrence after laparoscopic repair of paraesophageal hernia. Current English-language literature review. Case reports, series, and opinion articles on the use of mesh for paraesophageal hernia repair. Study type and results were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the procedure have been published to date. The information available showed that the use of a mesh for hiatal repair was safe and prevented recurrence. However, data on the long-term results were lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have not been confirmed.

The Massive Hiatal Hernia: Dealing With the Defect

The success of laparoscopic fundoplication has extended the use of the laparoscopic approach to treating more difficult situations such as paraesophageal hernias (PEHs) or type III (mixed) hiatal hernia. The results have shown that laparoscopic repair is feasible and safe. However, several series have shown recurrence rates of up to 42% as a result of difficulty in the closure of the hiatal gap. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure. This review analyses the different techniques proposed to prevent recurrence after laparoscopic repair of PEHs. The information currently available shows that the use of a mesh for hiatal repair is safe and prevents recurrence. However, data on the long-term results are lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience.