FUNDOPEXY, A MODIFIED APPROACH TO HIATAL HERNIA REPAIR IN SELECTED PATIENTS: SHORT-TERM OUTCOMES IN PRIMARY AND REOPERATIVE PROCEDURES
Clarissa Hoffman2, Mary Dyson*2, Megan Mai3, Andre Miler4, Farzaneh Banki1
1Cardiothoracic and Vascular Surgery, University of Texas Health Science Center, Memorial Hermann Southeast Esophageal Disease Center, Houston, TX; 2The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, TX; 3Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX; 4Memorial Hermann Southeast Hospital, Houston, TX
Introduction laparoscopic hiatal hernia repair with fundoplication results in good outcomes. Prevention of recurrent hiatal hernia remains a challenge. A modified approach with fundopexy was performed in selected patients with the aim to reduce recurrent hiatal hernia. Methods A retrospective chart review of hiatal hernia repairs with fundopexy in a single center was conducted. Outcomes were assessed by postoperative dysphagia requiring dilation, patients free of preoperative symptoms, use of PPI, patient satisfaction, and need for revisional surgery for symptomatic recurrent hiatal hernia. A questionnaire via phone was obtained to assess symptoms. Values are median (IQR). Tension-free intra-abdominal esophageal length and crural closure were obtained in all. Fundopexy was performed in patients age ? 60, hiatal hernia type III/IV, esophageal dysmotility and chief complaint of dysphagia. Fundopexy was performed by placing interrupted stitches below the gastroesophageal junction, at the level of divided short gastric vessels, between the entire fundus and the left upper-lateral abdominal wall, with the aim to maintain maximum intra-abdominal esophageal length and prevent recurrence. Results Out of 352 laparoscopic repairs, fundopexy was performed in 150/352 (42.6%), 123/150 (82.0%) primary repairs vs. 27/150 (18.0%) reoperative (all had a previous fundoplication). Comparing primary vs. reoperative; Age: 69 (58-76) vs. 66 (55-71), p=0.148, BMI: 29.7 (26.2-33.8) vs. 30.3 (25.3-33.3), p=0.932, ASA: III (III-III) vs. III (II-III), p=0.147, hernia type: III (III-IV) vs. III (II-III), p=0.001, size: 6 cm (4-8) vs. 4.5 (3.4-5.5), p=0.007. Duration of operation: 108 min (91-128) vs. 145 (129.3-170), p<0.001. LOS: 0 days (0-2) vs. 1 (0-2), p=0.229, 70/150 (46.7%) were same day surgery. Dysphagia requiring dilation: 17/123 (13.8%) vs. 8/27 (29.6%), p=0.082. Number of dilations: 1 (1-1) vs. 1 (1-2), p=0.771. Time to dilation (months): 0.8 (0.4-1.2) vs. 1.2 (0.6-2.0), p=0.256. At 11.5 months (6-14.8) none of 150 patients required reoperative surgery for symptomatic recurrent hiatal hernia. Questionnaire was obtained in 126/150 (84.0%) at 9.85 months (5.2-13.9), patients free of preoperative symptoms: 104/126 (82.5%), free of heartburn: 113/126 (89.7%), free of regurgitation: 116/126 (92.1%), free of dysphagia: 108/126 (85.7%), Free of bloating: 118/126 (93.7%), Off PPI: 113/126 (89.7%), Satisfied with operation: 116/126 (92.1%). Conclusion Fundopexy is a modified approach in laparoscopic hiatal hernia repair with good symptomatic relief and no need for revisional surgery in short-term. Fundopexy can replace fundoplication in selected primary repairs and seems an ideal alternative in patients with failed fundoplication. Longer follow up and larger population with objective diagnostic studies are needed to confirm long-term advantages of fundopexy.
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