Introduction: Laparoscopic paraesophageal hernia repair (LPEHR) with mesh has a lower recurrence rate (0-9%) compared to primary crural reapproximation (22-30%). It is unclear whether all LPEHRs require mesh or whether subgroups can be identified that are likely to recur without mesh reinforcement. The purpose of this study was to identify intra-operatively factors that are significantly associated with PEH recurrence.
Methods: 79 LPEHR were performed between 1997-2006, of which 45 were identified in a video library. 29 were excluded because they depicted redo-operations, mesh LPEHR, had insufficient follow-up, or were of too poor quality for review. Of the remaining 16 videos, 5 depicted repairs that recurred, based on a >3 month follow-up contrast study or gastroscopy. A 15-item tool (8 global rating likert scales and 7 checklist domains) assessing characteristics believed to be associated with recurrence was created. Three blinded surgeons with experience in LPEHR then viewed and independently rated the videos using these scales. For each item, median (IQR) scores for the 3 reviewers were compared for recurrent vs. nonrecurrent repairs using Mann-Whitney U-test or Fisher's Exact Test. Agreement between reviewers was determined with intra class correlation(ICC).
Results: Initial assessment of PEH size (p=0.9), anterior-posterior (p=1.0) or coronal hiatal diameter (p=0.2), amount of peritoneal stripping of crura (p=0.14), number of crural stitches used (p=0.8), and pexy of the fundoplication(p=0.6) were not significantly associated with PEH recurrence. Scores indicating poorer crural muscle quality (p<0.01), insufficient esophageal length (p=0.05), tension after crural closure (p<0.01), and surgeon dissatisfaction with crural closure (p=0.02) and with the repair overall (p=0.01) were significantly associated with PEH recurrence, while less complete hernia sac dissection/removal (p=0.08) and length of subdiaphragmatic esophagus (p=0.1) approached statistical significance. The median (IQR) total of these differentiating scores was 21 (17-24) in recurrent hernias and 13(12-15) in nonrecurrent hernias (p<0.01). A cut-off total score of 20 correctly classified all of the non-recurrent and 4 of 5 recurrent hernias. There was very good correlation of total score between the 3 raters (ICC 0.78 to 0.89 (p<0.01)).
Conclusion: Recognition of factors intraoperatively that are predictive of poor outcome after primary crural approximation may aide surgeons in selectively placing mesh during LPEHR.