MD Dariusz Kania
Resident in general surgery
Member of WALS
POLAND

Project to be submitted towards completion of Diploma in Minimal Access Surgery. World Laparscopy Hospital, India

Abstract:

Laparoscopic fundoplication was first described by Dellamagne in 1991. Since then it has become popular procedure in GI upper surgery. Nowadays laparoscopic antireflux surgery (LARS) is regarded as a gold standard in the treatment of gastroesophageal reflux (GER) with hiatal hernia. It offers good functional results, high long-term quality of life and success rate of 85-95% depicted in large protocols with long-term follow up evaluation.

Nevertheless there are several protocols describing hernia recurrence and intrathoracic wrap migration. Prothetic mesh was designed to reduce the number of potential postoperative recurrence. Firstly it was used during inguinal and ventral hernioplasty and the first laparoscopic fundoplication with mesh-reinforced hiatoplasty was published by Edelman in 1995. Since then there have been many randomised trials proving the efficacy of this procedure. Although hiatoplasty reduces the failure rate there are still points of controversy such as mesh erosion and migration to the esophageal/ stomach lumen and postinflammatory adhesiones or strictures.

Key words:

mesh erosion, gastrointestinal erosion, hiatoplasty, hiatal fundoplication, biomaterial, laparoscopic paraesophageal hernia,

Aims:

The aim of this article is to compare the effectiveness and safety of laparoscopic fundoplication with/without the mesh hernioplasty and its impact on postoperative complications. Controversial issues for both procedures are discussed. A literature search was performed in Pubmed/Medline to identify articles describing the efficacy of laparoscopic fundoplication with hiatal mesh reinforcement and its potential risk for gastrointestinal erosion or intrathoracic wrap migration. A literature compilation concerns the laparoscopic fundoplications procedure for gastroesophageal reflux disease (GERD) with hiatal hernia.

Indications for fundoplication:

Among the main cardinal symptoms leading to operation are reflux, dysphagia, anaemia, dyspnaea, chest burning. Another indications are chronic esophagitis and Barrett disease, combination of decreased lower esophagal sphincter pressure (LES) <6 mmHg and 24-hour pH monitoring with pathologic values. Also patients requiring long-term medical therapy and wanted to stop it or manifesting inadequate response to proton pump inhibitor (PPI) are candidates for laparoscopic fundoplication.

Risk factors:

Current paradigm shows tension-free meshed hernia repairs as the best technique for both inguinal and ventral hernias. Creating such approximation of diaphragmatic closure with the primary sutures is very difficult because of its permanent movement. The main reason for recurrence are inefficient crural approximation, vomiting in the early postoperative period and all activities causing heavy burden on diaphragm i.e. constipation, coughing, pregnancy, lifting heavy objects.

Diagnosis of GERD, hiatal hernia:

Patients undergo standard preoperative workup including clinical examination, routine blood analysis, chest X-ray, esophagogastroduodenoscopy with biopsy and histologic examination of GE junction, 24-h pH-monitoring and esophageal manometry, upper gastrointestinal barium x-ray study.

Evolution of laparoscopic fundoplication with mesh reinforcement:

The essential element of fundoplication success is closure of esophageal hiatus. The main reason for recurrence is inappropriate surgical procedure and anatomic characteristic of GE junction region. Diaphragmatic cruras consist of paraller muscular fibres with slight or no tendons reinforcement. Thus the crura closure with interrupted sutures generate the lateral tension proportional to the hiatal defect causing muscles tearing and disrupting during inspiratory movements or large intrabdominal pressure. Due to frequent aforementioned complications prothetic cruras reinforcement technique was invented. By reducing the lateral tension mesh hiatoplasty significantly reduces the hiatal hernia recurrence and intrathoracic wrap migration almost to zero, what was comfirmed in long-term follow up studies. Some authors postulate routine mesh superimpositon irrespective of hiatal hernia presence whereas the other recommend mesh implantation only if hiatal hernia is larger than 3 cm.

Operative procedures:

The laparoscopic Nissen fundoplication is a technique of choice during GERD with hiatal hernia. Operation starts with adhesiolysis. The lesser omentum is entered just above the hepatic branch of vagus nerve which should be preserved. Gastrohepatic ligament is divided up to the level of right crus of diaphragm. Then phrenoesophageal ligament is divided, gastroesophageal junction is mobilized and both vagus nerves are identified and left attached to the esophageus. Fundus is dissected by dividing the gastrophrenic ligament. Usually the short gastric vessels are cut to make the floppy Nissen possible. Stepwise intramediastinal mobilization of esophageus is performed until 4 cm of esophageus is brought to the abdomen. Then the retroesophageal window is created. In case the hernia exists the sack must be dissected and used as a cover for mesh cruroplasty. The crural repair is performed by 2-3 interrupted nonabsorbable sutures application between diaphragmatic pillars. The aim of these sutures is non-tension approximation of diaphragmatic cruras with 1 cm hiatal orifice left. Otherwise extra 1x3x4 cm polypropylene U-shaped mesh is superimposed on the crura with the open end of the U pointing anteriorly. Attention must be paid to prevent contact between mesh and esophagus. (0,5-1 cm distance is sufficient). Then 2-3 cm in length 360° floppy Nissen fundoplication is performed with 2 nonabsorbable stiches (silk). While performing fundoplication 60Fr orogastric bougie is inserted.

Usually the esophageus wall is incorporated into these sutures and there is an extra one for anchoring the wrap. Toupet fundoplication is performed when severely disordered peristalsis (>40% simultaneous contractions in wet swallows) or poor esophageal motility (<30mmHg in the lower esophageal segment in wet swallows) exists. General approach and dissection is similar to Nissen technique with the exception of 270° wrap formation. Usually the wrapped fundus is pulled behind the esophagus to the right side. Then a few sutures are placed between both the posterior left aspect of the fundus and the left crus and between the posterior right aspect of the fundus and the right crus of diaphragm to stabilize the wrap.To form a 2-3 cm wrap a few sutures are put between the fundus to the left of the esophagus, the anterior wall of esophagus and the anterior wall of wrapped portion of fundus. One of the main reason for recurrence remain short esophageus that’s why 4 cm distal part of it must rest freely (without tension) in epigastric cavity. Otherwise collis gastroplasty must be performed.

Operative time :

Median operative time of fundoplication with simple suture hiatal closure is 120 min. The mesh fixation extends the median operation time for extra 15 minutes (mesh fixed with tackers).

Mesh fixation:

Usually 6x9 cm (+/- 2 cm) butterfly-shaped mesh is placed behind the esophagus using onlay position and fixed by tackers/staples to the diaphragram and cruras. In another technique a circular shaped mesh is cut from 10x15 cm sheet. A 3-4 cm keyhole for esophageal body is cut out. After placing on the diaphragm and approximated cruras the mesh is fixated circumferently with tackers/staples. One should remember about anatomical retrictions i.e. left liver lobe anteriorly, aorta posteriorly, vena cava inf. to the right and spleen to the left.

There is no constant agreement about material, size and shape of the mesh. Granderath at al. conducted a pilot study in which the hiatoplasty technique was tailored to the size of hiatal surface area (HSA). They used single sutures for HSA £ 4cm2, single sutures with a 1x3 cm polypropylene mesh for HSA > 4 cm2 and strong crura, single sutures with dual Parietex mesh for HSA > 4 cm2 with weak crura, and tension-free (no approximating sutures) PTFE for HSA > 8 cm2. During the 6,3-month follow-up only one patient developed intrathoracic wrap migration. Data are promising but further research with longer follow-up are needed.

Anaesthesia:

Total intravenous anesthesia (TIVA) is performed to improve patients early recovery.

Patient position:

Usually patient is placed in modified supined position with 20°-30° reversed Trendelenburg tilt and legs abducted.

Position of surgical team:

French position is the most common. Surgeon stands between the patient’s abducted legs, on surgeon’s left side camera operator stands and on the patient’s left side assistant and scrub nurse stand.

Port position:

Following the Baseball Diamont Technique five trocars are placed in epigastrium in following position: The 10-mm trocar is placed in the middle of the xipho-umbilical line. The left operating 5-mm trocar is placed in the right subcostal region in a right paramedian line 5 cm lateral of the first trocar. The right operating 10-mm trocar is placed in the left subcostal region. A third 5-mm left lateral subcostal trocar is placed for purposes of exposure. A final 5-mm right median subcostal trocar allows retraction of the liver. In obese patients, the latter trocar is placed closer to the xiphoid process.

Choice of mesh:

The most popular mesh material is polypropylene, polytetrafluoroethylene (PTFE) and porcine small intestine submucosa but no comparative trials about type mesh have been performed yet. It seems that apart from simplicity of mesh fixation and its ability to making adhesions on the diaphragmatic side important factors in mesh selection is its price and market availability. Some studies mentioned about postoperative complications after polypropylene mesh application. All this happen since prolypropylene mesh creates substantial visceral adhesions to adjacent organs. Nowadays there is a trend to use material that provides little potential for adhesion formation and fistulization, such as PTFE. Fluoroscopy examination with the use of PTFE corroborates decreased visceral adhesion formation as well as normal diaphragmatic motion. It works like a buttress while diaphragmatic stretching because of coughing, straining, retching or obesity.

Postoperative evaluation:

The evaluation of quality of life and satisfaction was conducted by GERD Health-Related Quality of Life (HRQL) questionnaire.

Hospital stay:

Postoperatively intravenous (IV) metoclopramide and PPI are administered against belching and vomititng. Patients are discharged 3-17 (mean 8+/-2) days postoperatively.

Intraoperative complications:

Complication rate is up to 9% including pleural injury, capsule spleen laceration, gastric perforations, esophageal injury. 0,6% conversion are performed due to adhesions post previous open fundoplication.

Postoperative morbidity:

The perioperatively transient dysphagia, gas bloat and heartburn regurgitation are complained and symptoms resolve after 3-6 weeks in 10-15 % cases. In comparative study mesh-reinforced hiatoplasty is associated with higher dysphagia rate which dicreases in time and after 1 year follow-up it becomes comparable to dysphagia rate of patients who underwent simple sutured hiatal closure. Mesh application is associated with higher LES pressure, but no significant differences in esophageal body motitlity, LES length and relaxation, intraabdominal LES pressure are found between these two groups. Patients show improvement in the quality-of-life evaluation by GERD-HRQL questionnaire with significant difference according to dysphagia and bloat syndrome in the group with mesh-reinforced hiatoplasty.

During the long-term follow up some patients develope postoperative symptoms like fullness, meteorismus, reflux, retrosternal and epigastric pain, flatulence, dyspnea and diarrhoea. Despite quite big proportion of postoperative side-effects (64%) most patients are satisfied with the postoperative results (outcome assessed as good or very good) and would agree to undergo operation again (96%). Some authors mention about 14% postoperative complications such as pneumonia, atelectasis, pleural effusion, esophageal spasm.

In most articles there are no information about mesh-related complications. Only a few articles have mentioned so far about erosion and stricture of the esophagus, mesh extrusion, bowel erosion, fistulization to gastrointestinal organs and wound sepsis. In one trial during 4 years follow-up 1 mesh connected complication occured of 204 patients. In 2009 a case of severe aorta bleeding 1 week after mesh hiatoplasty fundoplication was published.

Recurrence:

Among the patients with preoperative diagnosed hiatal hernia, 19% of ones who underwent fundoplication without mesh experienced hernia recurrence, 5,5% developed wrap migration into the thorax. 1,8% of ones who underwent mesh hiatoplasty experienced hernia recurrence. Laparoscopic fundoplication with mesh improved the quality of life to the same level as the classic operation. What is more, patients with mesh more often complained of transient dysphagia and after one year no differences were found. In another protocol among 729 patients who underwent fundoplication with primary suturing hiatoplasty 10,7% had recurrence/migration whereas 1,8% of recurrence/migration was assessed among 639 patients after mesh superimposition. The most common pattern of postoperative recurrence are paraesophageal hernia, hiatus failure, intrathoracic wrap migration (slipped Nissen) and wrap failure. In one study 176 mesh reinforcement fundoplications were performed and during the two year follow-up no mesh infection were detected. These data are comparable with other trials.

Another reason for postoperative failure is muscular diaphragmatic illness caused by collagen impairment. Probably the apprioprate flat fixation of mesh to the pillar structures and covering it with the hiatal hernia sack play a role in additional postoperative recurrence rate reduce.

Future prospects of laparoscopic fundoplication:

New biomaterials used as mesh are needed to be developed with the particular emhasize on creating temporary scaffolding for native tissue ingrowth simultaneously eliminating the risk of erosions into gastrointestinal tract. Studies with the use of small intestinal submucosa (SIS) and acellular human dermal matrix mesh are needed. Also further technological progress can make SILS fundoplication comfortable, safe and efficient.

Conclusion:

Laparoscopic antireflux surgery with the mesh hiatoplasty is safe and effective procedure. No tension technique allows to reduce significantly the postoperative recurrence rate resulting excellent upper GI functioning, quality-to-life improvement and consecutive high patient satisfaction. The main drawbacks against using mesh hiatoplasty could be visceral erosions or adhesions related to the implemented foreign body. Although aforementioned complications happen in 0,1-20% cases it must be said that there is a dependence between the surgical experience and the lower incidence of complications. There have been performed no scientific inqueiries concerning the selective use of mesh, its size, shape and type composition yet. In the literature number of the individual cases describing postoperative intra stomach/esophageal mesh migration is very low even in large and long-term follow up protocols and does not represent the contraindication of mesh application. The current data tend to support the PTFE mesh application in routine laparoscopy fundoplication. Further randomised trials are needed to assess the potential drawbacks against routine mesh hiatoplasty.

References

1. Laparoscopıc Fundoplicatıon with Prosthetic Hiatal Closure İlknur Kepenekci World J Surg. (2007) 31.2169-2176, DOI: 10.1007/s00268-007-9066-7
2. Laparoscopic management of large paraesophageal hiatal hernia. Leeder PC, Smith G, Dehn TC. Surg Endosc. 2003 Sep;17(9):1372-5. Epub 2003 Jun 25.
3. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Frantzides CT, Carlson MA. Surg Endosc. 1997 Jul;11(7):769-71.
4. Department of Surgery, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
5. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Müller-Stich BP, Holzinger F, Kapp T, Klaiber C. Surg Endosc. 2006 Mar;20(3):380-4. Epub 2006 Jan 21.
6. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Soricelli E, Basso N, Genco A, Cipriano M. Surg Endosc. 2009 Nov;23(11):2499-504. Epub 2009 Apr 3.
7. Laparoscopic surgery into mixed hiatal hernia. Results pre-operative and post-operative. Pagán Pomar A, Palma Zamora E, Ochogavia Segui A, Llabres Rosello M. Rev Esp Enferm Dig. 2009 Sep;101(9):623-30. English, Spanish.
8. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature. Johnson JM, Carbonell AM, Carmody BJ, Jamal MK, Maher JW, Kellum JM, DeMaria EJ. Surg Endosc. 2006 Mar;20(3):362-6. Epub 2006 Jan 25.
9. Severe complication of laparoscopic mesh hiatoplasty for paraesophageal hernia. Zügel N, Lang RA, Kox M, Hüttl TP. Surg Endosc. 2009 Nov;23(11):2563-7. Epub 2009 May 14.
10. Laparoscopic repair of paraesophageal hernias: a Canadian experience. Boushey RP, Moloo H, Burpee S, Schlachta CM, Poulin EC, Haggar F, Trottier DC, Mamazza J. Can J Surg. 2008 Oct;51(5):355-60.
11. Laparoscopic revisional fundoplication with circular hiatal mesh prosthesis: the long-term results. Granderath FA, Granderath UM, Pointner R. World J Surg. 2008 Jun;32(6):999-1007.
12. Antireflux surgery with routine mesh hiatoplasty. Trindade EN, Trindade MR. World J Surg. 2008 Feb;32(2):328; author reply 329-30. No abstract available
13. Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Granderath FA, Schweiger UM, Pointner R. Surg Endosc. 2007 Apr;21(4):542-8. Epub 2006 Nov 14.
14. Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: Results of a prospective randomized trial. Granderath FA, Kamolz T, Schweiger UM, Pointner R. Arch Surg. 2006 Jul;141(7):625-32. Erratum in: Arch Surg. 2007 Jun;142(6):579 FREE
15. Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery. Granderath FA, Kamolz T, Schweiger UM, Pointner R. Arch Surg. 2003 Aug;138(8):902-7.
16. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia.Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. Arch Surg. 2002 Jun;137(6):649-52.
17. Dysphagia and quality of life after laparoscopic Nissen fundoplication in patients with and without prosthetic reinforcement of the hiatal crura. Kamolz T, Granderath FA, Bammer T, Pasiut M, Pointner R. Surg Endosc. 2002 Apr;16(4):572-7. Epub 2002 Jan 9.