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Laparoscopic Management of Hiatus Hernia
Table 3: Intraoperative parameters
Mesh Blood loss Operative time Hospital stay
No 60.00 SD 14.142 mL 122.00 SD 10.00 minutes 4.20 SD 0.816 days
Yes 65.29 SD 21.828 mL 134.12 SD 13.257 minutes 5.18 SD 1.286 days
Total 62.14 SD 17.605 mL 126.90 SD 12.781 minutes 4.60 SD 1.127 days

Table 4: Complications hernia repair and mesh reinforcement, with similar results in both
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Mesh synthetic and biologic mesh. Zhang et al., Huddy et al., and Tam
Complications No Yes Total et al. have found a reduced rate of hernia recurrence after mesh
reinforcement compared to primary suture repair at short-term
Diarrhea 1 (2.4%) 0 (0.0%) 1 (2.4%) follow-up (up to 12 months). 19–21 Recent studies have indicated that
Dysphagia 4 (9.5%) 6 (14.3%) 10 (23.8%) the fundoplication is the necessary step in all hiatal hernia repairs
Gas bloat 4 (9.5%) 6 (14.3%) 10 (23.8%) due to the incompetent lower esophageal sphincter and extensive
Pulmonary complication 1 (2.4%) 2 (4.8%) 3 (7.1%) hiatal dissection, which may also potentiate reflux. 25
Total 10 (23.8%) 14 (33.33%) 24 (57.14%) In our series, we performed a total of 37 (88.1%) 360° Nissen
floppy fundoplications. In four (9.52%) patients, we performed
In 24 (57.14%) patients, minor, manageable complications were partial posterior fundoplication according to Toupet. One
observed in intra- and postoperative follow-up of 2 years. Dysphagia patient (2.38%) underwent gastropexy. The conversion rate to
and gas bloat being the most common, and each was observed in open procedure was 4.8% (two patients), mainly because of
10 (23.8%) patients. Pulmonary complication was observed in three technical difficulties in very obese patients. The average length of
(7.1%) patients owing to the mediastinal dissection. Out of three, hospitalization was 4.6 (SD 1.12 days). The 30-day death rate was
22,13
pneumothorax was detected in one (2.4%) of the patients, which zero. Similar results were obtained in other series.
was managed by putting chest tube and thereafter patient was Although chances of recurrence are more with PTFE mesh,
managed conservatively. Complication profile of the patients is but with least adhesions, vice versa holds true for polypropylene
shown in Table 4. mesh. In our study, mixed mesh was used to have least adhesions
There was no mortality in 30 days postoperatively. This and recurrences. Our study showed recurrence rate of 7.1%, and all
procedure was satisfactory (defined as symptom relief and with no the recurrences occurred in the type III hernia in which mesh was
hiatus hernia in postoperative barium meal) in 39 (92.9%) patients. not used similar to the study done by Morino et al. in which the
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Recurrence occurred in three (7.1%) patients of type III hernia in recurrences decreased by using a mixed mesh. In hiatal hernia,
whom only fundoplication was done without mesh placement. Nissen fundoplication is a time-proven procedure with various
These patients were re explored, and mesh was placed after crural modifications. In a 1,340 case series, 1,248 (93.1%) patients had
24
repair. They had an uneventful postoperative period. satisfactory outcome over a period of 5 years. Out of 42 patients in
our study, 39 (92.9%) patients had satisfactory results. Multiple studies
have reported that complications occur rarely after mesh fixation. 25
dIscussIon Dysphagia is the most common complaint in first week after
26
Laparoscopic surgery provides the advantages of a minimally Nissen fundoplication. Although resolving spontaneously,
invasive approach, which consist of shorter hospital stays, faster endoscopic dilatation is required in patients who had persistent
time of recovery, reduced postoperative pain, and reduced dysphagia over the long term. In a 50 case series, three (6%) patients
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pulmonary complications. 11,12 were operated with repeat laparoscopic surgery for dysphagia.
The standard surgical technique include stomach reposition, Some studies have reported the rate of dysphagia in excess of 13%
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crural repair, and antireflux procedure. Hernia sac dissection and after mesh placement. In the study done by Soricelli et al., the
complete detachment from the mediastinal pleura are mandatory. recurrence rate dropped from 1.8% with the tension-free technique
29
After doing so, it is possible to return the stomach and GEJ to its to 1.1% with the use of cruroplasty and mesh placement. In our
13
usual infradiaphragmatic position in a tension-free manner. At technique, U-shaped mesh was used to decrease the dysphagia rate.
the completion of hiatal dissection, the intraabdominal esophagus Our study showed dysphagia in 10 (23.8%) patients (mesh: 6, 14.3%;
should measure at least 2–3 cm in length to decrease the chance nonmesh: 4, 9.5%) who were managed conservatively without any
of recurrence. The goals of the surgery as described by Stein and surgical intervention for dysphagia.
DeMeester should be construction of a short, loose 360-degree
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fundoplication. In our series, we performed a total of 25 (59.52%) conclusIon
posterior cruroraphies. In the cases of large hiatal defect and friable This study concluded that laparoscopic management of hiatus
crura, the crura repair should be reinforced. Some authors suggest hernia is a feasible and safe option, with a very low morbidity and
15
routine use of pledgets to lessen the pressure on the suture line. mortality rate. The patient satisfaction rate was excellent, and
Some authors recommend the use of a synthetic mesh inpatients postoperative complications were minimum and manageable.
16
with the hiatal defect larger than 8 cm in cruralseparation. In
17 (40.48%) cases with the hiatal defect larger than 8 cm, we references
reinforced the primary crural repair with an only application of 1. Skinner D, Belsey R. Surgical management of esophageal reflux
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“U”-shaped synthetic mesh fixed by tacks. Zaman and Lidor have and hiatus hernia. J Thorac Cardiovasc Surg 1967;53(1):33–54. PMID:
found a decrease in recurrence after laparoscopic paraesophageal 5333620.

210 World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021)