HIATAL LOCATION OF RECURRENT HIATAL HERNIA: A LESSON TO WHERE REPAIR AND REINFORCEMENT ATTENTION SHOULD BE DIRECTED?
Adham Saad*, Vic Velanovich
Surgery, University of South Florida, Tampa, FL
Background: Recurrence after hiatal hernia repairs is not unusual. This has led to several adjuncts being applied in practice to reduce these occurrences. Such adjuncts include placement of mesh of varying materials and configurations and relaxing incisions. However, these adjuncts have generally been focused on the posterior crural closure. Our observation is that recurrences are not related to disruption of the posterior crural closure, but in locations on the hiatus that was not approximately or reinforced with mesh.
Methods: Consecutive patients who underwent repair of recurrent hiatal hernias from 3/2012 to 11/2018 were reviewed. Data gleaned included age, sex, date of operation, location of hiatal hernia recurrence (anterior, posterior, circumferential), operative approach (laparoscopic, open laparotomy, laparoscopic converted to open, thoracotomy), method of hiatal hernia repair (none, suture repair, suture repair reinforced with biologic mesh), fundoplication preformed (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, Belsey), need for gastrectomy, and additional procedures (pyloroplasty, gastrostomy tube, feeding jejunostomy tube).
Results: 91 consecutive patients were studied. There were 67 females, 24 males, with a mean age of 61 + 15 years (range: 18-84 years). Recurrences were found in the following locations: anterior 65, posterior 5, and circumferential 21. 50 repairs were done with open laparotomy, 34 laparoscopically, 6 laparoscopic converted to open, and 1 thoracotomy. 10 patients had no hiatal repair, 35 primary suture repair, and 46 suture repair reinforced with biologic mesh. 13 patients had no fundoplication, 43 Nissen, 15 Toupet, 7 Dor, 9 Collis-Nissen, 3 Collis-Toupet and 1 Belsey. 6 patients required a gastrectomy. 14 patients had a pyloroplasty, 5 a gastrostomy tube, and 6 a feeding jejunostomy tube.
Conclusion: Repair of recurrent hiatal hernias are challenging and require a thoughtful approach. However, the real lesson in recurrent hiatal hernia repairs is understanding that the location of the recurrence is usually not associated with the site of the original repair. Surgeons need to also pay attention to approximating and, possibly, reinforcing the anterior aspect of the hiatus during the original repair.
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