Introduction: In 1973, Allison reported a 49% recurrence rate in 421 paraesophageal hernia (PEH) cases followed over 22 years. A more recent study shows a recurrence rate of 30% following a laparoscopic repair without mesh. The placement of mesh has been shown to decrease the PEH recurrence to less than 7% in some studies. Typical synthetic mesh are easy to use but have an unacceptable rate of erosion into the esophagus. Biologic mesh have recently gained favor as an alternative for crural reconstruction of PEH. In a recent randomized, prospective study by Oelschlager, recurrence rates decreased from 25 to 9% with the use of biologic mesh. However, a simple method for placing and securing the mesh to the diaphram has never been described. Methods that have been suggested include sutures, tacks, and staples, but risk complications of mesh migration, diaphragmatic injury, and pericardial injury as well as increased cost. We have employed a technique of crural incorporation (CI) of the biologic mesh into the closure of the diaphragmatic hiatus. We hypothesize that this method of crural repair will decrease the rate of hernia recurrence and avoid the cost and complications of other mesh placement techniques.
Methods: The pre-operative and post-operative data from 35 patients operated on from December 2005 to May 2007 was analyzed, including pre- and post-op EGD, manometry, and UGI. All patients were pre-operatively diagnosed with PEH using one or all of the tests formerly mentioned. A structured systems assessment tool was also administered to all patients pre- and post-operatively. All pts underwent PEH repair with CI. Biologic mesh was incorporated into the crural closure using pledgeted zero polyester suture in a horizontal mattress stitch. Mean follow-up was 6.1 months (range 1-16 months).
Results: Pre-operatively, 60% of pts had GERD symptoms, 42% pulmonary symptoms (SOB, cough), and 25% had chest pain. Post-operatively 100% of pts had resolution of their pre-op symptoms. 5/35 (14%) of pts were found to have post-operative dysphagia. Twenty-one pts had post-op studies (egd, manometry, or UGI). No patients were found to have recurrence of their PEH. No intra-operative complications were noted.
Discussion: The use of biologic mesh has been demonstrated to decrease recurrence rates following PEH repair. The safest and most efficient method of mesh placement has not been defined. Our method of PEH repair with CI decreases the rate of mesh complications and the rate of recurrence while utilizing no extra suture or staples, while providing excellent apposition of mesh to the underlying crura and securely closing the hiatus.