Page 50 - World Journal of Laparoscopic Surgery

Preventing Mesh Complications at Hiatus
slit in the mesh accommodates the esophagus and the prolene initial transient dysphagia which may occur due to postoperative
surface directed toward the diaphragm and composite surface edema at the gastroesophageal (GE) junction. Gradually from
facing the peritoneal cavity. Appropriate fundoplication wrap was the 2nd week onward, patients were started on solid food. For
carried out. Falciform ligament was released from its attachment the assessment of the integrity of the cruroplasty and wrap in all
to the ventral abdominal wall taking care of not hampering its the subjects, postoperative UGI scopy and CT scan were done at
vascularity (Fig. 1) and then it was placed in between the mesh and 12 and 24 months following surgery.
the posterior esophagus to avoid direct contact between the mesh
and the hollow viscera (Figs 2 and 3).
results
Postoperative Course Sixteen patients were included in the study (60% females).
Patients were started on liquid diet 4 hours following surgery. For Twelve patients had been operated on for redo hiatus hernia
the initial 1 week, patients were given only liquid diet to prevent the surgery for recurrence and four patients were operated on
for a large hiatus hernia. The average age of the patients was
48.5 ± 11.5 years (mean ± SD) and the average BMI of the patients
was 24.8 ± 1.6 (mean ± SD). All patients had undergone pre and
postoperative manometry and UGI scopy. The operative time was
128.2 ± 24.2 minutes (mean ± SD) after the insertion of the first
trocar and the average hospital stay for patients was 72 hours. In
all the patients in this study group, a composite prosthetic mesh
was used for augmentation of the hiatal closure and released
ligamentum teres were placed between the mesh and esophagus
preventing the mesh to come in direct contact with the hollow
viscera thereby reducing mesh-related complications. None of
the patients had a recurrence of hiatus hernia or had any long-
term dysphagia following surgery. In none of the patients, any
mesh-related complications were observed on 2-year follow-up.
Fig. 1: Releasing falciform ligament from the ventral abdominal wall No unexpected event was observed in these patients following
the addition of a simple step of ligamentum teres pedicle between
the mesh and the hollow viscera during LARS with mesh prosthesis
at the hiatus.

discussion
Use of prosthetic mesh at the hiatus in large hiatus hernias or
in redo hiatal hernia surgeries has been well documented and
practiced. But the concern about its use at the hiatus has also
been raised due to the complications like mesh directly eroding
6,7
into the digestive lumen. In our series of over 1,500 hiatal hernia
surgeries, the composite mesh was used in only 30 patients. In
this very small subset of patients with mesh used at hiatus, we
encountered a case of mesh eroding into the stomach. Hence mesh
erosion is a significant problem that is not uncommon and has been
Fig. 2: Falciform ligament placed between mesh and the posterior underreported in the literature.
esophagus/wrap (view from the right side) The benefit of using mesh at hiatus in large hiatus hernias
or redo surgeries is certainly present to prevent the recurrence.
8,9
With the two randomized trials, it becomes obvious that using
a prosthetic mesh at hiatus for large defects prevents long-term
recurrence and is a better-quality repair compared to simple
suture repair. But the complication like mesh erosion raises the
concern about its use. A significant morbidity is associated with
10
mesh erosion. Role of biologic mesh for long-term prevention of
recurrence of hiatus hernia has also been questioned. Oelschlager
et al. in their long-term follow-up with the use of biological mesh at
the hiatus did not find any mesh-related complications but were not
able to determine the benefit of using biological mesh to prevent
long-term recurrence of large hiatus hernia. 11
The use of falciform ligament to buttress the cruroplasty to
provide strength to primary suture repair has also been described
Fig. 3: Falciform ligament placed between mesh and the posterior in the literature. 12,13 Its long-term results are not present and there
esophagus/wrap (view from the left side) has been no randomized trial comparing the use of mesh to the

48 World Journal of Laparoscopic Surgery, Volume 15 Issue 1 (January–April 2022)