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Introduction: Laparoscopic paraesophageal hernia repair (LPEHR) is the preferred treatment for symptomatic paraesophageal hiatal hernia in specialized centers. LPEHR has yielded excellent perioperative outcomes and symptom control; however, it has been associated with high radiographic recurrence rates. Hiatal reinforcement with PTFE mesh prevents hernia recurrence, but is associated with unacceptable mesh related complications. Conversely, bioabsorbable mesh placement has proven safe, but failed to produce long term reductions in hiatal hernia recurrence. The primary objective of this study was to review a single institution experience to evaluate the initial safety and efficacy of LPEHR with crural reinforcement using a polyester composite mesh.

Methods: A retrospective review of patients undergoing LPEHR from 2006-2011 was conducted under an institutional review board approved protocol. All patients who underwent LPEHR with placement of polyester composite mesh were contacted for study enrollment. Long-term follow-up evaluation was performed in person or by telephone questionnaire. Outcomes included barium esophagram, GERD health related quality of life (GERD-HRQL) assessment, and patient satisfaction with their operation. Significant reflux was defined as a GERD-HRQL score > 12.

Results: Between 2006 and 2011, 175 patients underwent LPEHR, and polyester composite mesh was used for hiatal reinforcement in 29 cases. Twenty (70%) patients completed the questionnaires, and 12 (41%) patients returned for a post-operative barium esophagram to assess for hernia recurrence. The median follow-up interval was 29.5 (6-66) months, and esophagrams were performed at a median of 34 (9 - 66) months following LPEHR. There were no mesh related complications within the study group. Eight of the twelve patients (75%) who underwent a radiographic evaluation with barium had evidence of recurrence. The incidence of significant reflux was 15%. There was no significant difference between the median GERD-HRQL scores between those with radiographic recurrence and those without (p = 0.732). Fifteen percent (n=3) of patients reported moderate to severe dysphasia, and esophagram demonstrated a recurrent hiatal hernia in each case. Eighty-one percent of patients polled reported being satisfied with their surgery, and 86% reported that they would, with the benefit of hindsight, have their surgery again.

Conclusions: LPEHR with polyester composite mesh reinforcement provides durable symptomatic relief with high levels of patient satisfaction at intermediate follow-up. No mesh related complications or side effects occurred in this series. While anatomic hiatal hernia recurrence detected by routine post-operative imaging is common, most of these are asymptomatic and do not correlate with patient symptoms or dissatisfaction with the operation.