Page 49 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Prevention of Mesh-related Complications at the Hiatus:

A Novel Technique Using Falciform Ligament

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Pranav Mandovra , Vishakha R Kalikar , Roy V Patankar 3
AbstrAct
Aim: In this study, a technical modification has been performed by using falciform ligament between the mesh and esophagus thereby preventing
mesh to come in direct contact with the hollow viscera so reducing mesh-related complications.
Materials and methods: From January 2016 to December 2017, patients requiring the use of prosthetic mesh at the hiatus during laparoscopic
antireflux surgery (LARS) surgery were included in the study. Principles of an ideal LARS have adhered. After mesh repair at hiatus and appropriate
fundoplication, the falciform ligament was released from its attachment to the ventral abdominal wall and was placed between the mesh
and the posterior esophagus avoiding direct contact between the mesh and hollow viscera. Postoperatively patients were followed up for a
minimum of 2 years. A retrospective analysis was done of the prospectively collected data.
Results: Sixteen patients were included in the study (12 patients had redo surgery and four had large hiatus hernia requiring prosthesis). Average
age of the patients was 48.5 years and the average BMI was 24.8. The mean operative time was 128.2 minutes. None of the patients had a
recurrence of hiatus hernia, long-term dysphagia, any mesh-related complication, or any unexpected event related to surgery on 2-year follow-up.
Conclusion: This innovative technique of using falciform ligament as a bridge between the mesh and the esophagus prevents the mesh-related
complication without compromising the strength of hiatal repair.
Clinical significance: To prevent the recurrence of hiatus hernia, the use of prosthetic meshes is advocated in patients with large hiatal surface
areas. Concern about the safety of mesh at the hiatus has been there. This technique helps in reducing the mesh-related complication at the hiatus.
Keywords: Falciform ligament, Mesh at hiatus, Prevention of mesh complications.
World Journal of Laparoscopic Surgery (2022): 10.5005/jp-journals-10033-1497

bAckground 1–3 Digestive Disease Centre, Zen Multispecialty Hospital, Mumbai,
Laparoscopic cruroplasty with fundoplication has emerged as a Maharashtra, India
standard of care for patients with symptomatic hiatus hernia and Corresponding Author: Pranav Mandovra, Digestive Disease
paraesophageal hernias. Reconstructing the widened esophageal Centre, Zen Multispecialty Hospital, Mumbai, Maharashtra, India,
hiatus forms an integral part of the surgery for hiatus hernia. Phone: +91 9712985876, e-mail: pranavmandovra@gmail.com
Primary suture repair and doing only cruroplasty for large hiatal How to cite this article: Mandovra P, Kalikar VR, Patankar RV.
1,2
hernias are associated with high recurrence rates. To prevent the Prevention of Mesh-related Complications at the Hiatus: A Novel
recurrence of hiatus hernia, the use of prosthetic meshes has been Technique Using Falciform Ligament. World J Lap Surg 2022;15(1):
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well advocated in patients with large hiatal surface areas. With the 47–49.
increasing use of mesh at the hiatus, few reports of intraluminal Source of support: Nil
4,5
mesh erosion were published. This rose the concern about the
safety of mesh use at the hiatus. Even the composite meshes are Conflict of interest: None
known to erode intraluminally.
In this study, a technical modification has been performed manometry, and CT scan. Patients were carefully selected for
to use falciform ligament between the mesh and esophagus LARS. The prosthetic mesh was used in all patients with redo
preventing mesh to come in direct contact with the hollow viscera LARS for recurrence of hiatus hernia or wrap migration or patients
thereby reducing mesh-related complications. undergoing primary LARS with a large hiatus hernia with a
maximum intercrural distance of more than 5 cm at the end of
Methods And MAteriAls dissection.
This is a pilot study with a limited sample size but an innovative
concept performed at a tertiary healthcare center in Mumbai, Operative Technique
India. Patients undergoing laparoscopic antireflux surgery (either All the principles of an ideal LARS were adhered. Adequate
primary or redo surgeries for hiatus hernia) from January 2016 to mobilization with a minimum 5 cm length of the intra-abdominal
December 2017 requiring the use of prosthetic mesh at the hiatus esophagus was achieved. An attempt was made to achieve tension-
were included in the study. Patients undergoing LARS in whom free crural closure, but in cases of large defect at hiatus where
prosthetic mesh was not used were excluded from this study. This tension-free suturing was not possible darning sutures were taken
study was approved by the ethics committee of our institution. to create a bed for the mesh. A composite mesh was refashioned
In all the symptomatic patients a thorough preoperative with a “U”-shaped slit that was created in the mesh which was used
evaluation was done including upper GI scopy, upper GI at the hiatus posterior to the esophagus in such a way that the “U”

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