TECHNIQUE AND EARLY RESULTS OF ROBOTIC HARVEST OF A VASCULARIZED POSTERIOR RECTUS SHEATH AS AN ONLAY FLAP FOLLOWING HIATAL HERNIA REPAIR.
Chase G. Corvin*, Lawrence Gottlieb, John Alverdy, Yalini Vigneswaran
Surgery, The University of Chicago Medicine, Chicago, IL
Background: Despite the availability of prosthetic material to repair recurrent and large complex paraesophageal hernias, recurrences and complications remain unacceptably high. We have recently reported on the use of the patient's own posterior rectus fascia as a well vascularized onlay graft following as standard cruroplasty. Here we report the early results of a limited series of fifteen patients and offer refinements in the technique using robotic surgery.
Methods: A group of fifteen patients were selected who either presented with large attenuated hiatal hernia defects (n=10) or recurrent hiatal hernias (n=5). Using a robotic technique, the hernia is reduced in the usual fashion. A well vascularized portion of right posterior rectus fascia (approximately 5x7 cm) is then harvested by preserving the vascular pedicle of the round ligament. To alleviate any tension, the flap is passed under the left lobe of the liver, cut to encircle the esophagus, and laid over the cruroplasty. The flap is sutured posteriorly and anteriorly to the diaphragm using interrupted or running sutures (see figure). Postoperative clinical metrics included length of stay, 30-day readmissions, clinical complications, and six month esophagram.
Results: Our series included 12 women and 3 men with mean age of 73 years (62-80), BMI of 27 (22-37) and 9 month follow up. Later in the series, additional time to harvest the flap was approximately 30 minutes. All patients recovered similar to our historical non-flap patients with no alterations in postoperative pain or length of stay. When symptoms regarding any right abdominal pain were specifically solicited, no symptoms were noted. One patient experienced right sided abdominal wall bruising that resolved spontaneously. All patients were satisfied with their repairs at an average follow up of 9 months (0-22 months). To date, no clinical recurrences have been noted based on elicited symptoms, and on available imaging (UGI, CT scan) only one small recurrence (2.7cm) was identified without evidence of clinical symptoms.
Conclusions: The use of posterior rectus fascia for hiatal reconstruction provides many advantages of using durable, autologous, vascularized tissue with a peritoneal lining to buttress the crural repair and is technically feasible with a minimal impact on operative time or post-operative recovery as seen in this 15 patient series. In patents with a difficult to repair hernia, a reinforced repair with the strength of autologous fascia appears to have the appropriate risk-benefit profile over use of mesh. Although in this current series short-term recurrence rates were low, larger sample sizes and long-term outcomes are needed to determine the efficacy of this repair and its selection criteria.
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