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HIATAL HERNIA REPAIR WITH NOVEL LIVER LIGAMENT RELEASE AND MESH PLACEMENT
Pavani Peddi
*, Rahul Mhaskar, Christopher DuCoin
Gastrointestinal Surgery, University of South Florida, Tampa, FL
Introduction: Hiatal hernia is a complex pathological condition characterized by a high recurrence rate regardless of mesh placement during repair. Large hernias exhibit a greater propensity for recurrence. Additional factors contributing to recurrence include advanced age, obesity, and presence of substantial defects. The anterior aspect was more frequently associated with recurrence. The objective of this study was to compare the recurrence rate of hernia using a novel technique of mesh placement with the conventional procedure.
Materials and Methods: A retrospective single-center study was conducted on patients who underwent robotic hernia repair with mesh placement. All hiatal hernia repairs without mesh placement were excluded from the study. Of the 147 patients, 26 underwent mesh placement utilizing the keyhole/starburst technique, while 121 patients underwent mesh placement employing a novel technique. In the new technique, a space is created between the left triangular ligament and the diaphragm, wherein a mesh is subsequently positioned posterior to the ligament and sutured to the central tendon and crura. Postoperatively, patients were evaluated for symptomatic improvement. Recurrence was defined as a hiatal hernia larger than 2 cm on either upper gastrointestinal endoscopy and/or swallowing study, with or without symptoms. Statistical analysis was performed using SPSS software.
Results: No significant differences in demographic data were observed between the two patient groups. Among the 147 patients, 87.5% presented with type 3 hernias, while 12.5% exhibited type 4 hernias. Additionally, 25.9% of patients underwent the Redo procedure, and 74.1% received primary repair. Toupet fundoplication was the predominant type of fundoplication employed in patients utilizing the new technique, whereas Nissen fundoplication was most prevalent in the old technique. Symptomatic improvement was significantly more pronounced in the new treatment group (p=0.017). Recurrence was observed in 8 (6.6%) out of 121 patients in the new group and 5 (20.8%) out of 19 patients in the old group, with a p-value of 0.042, indicating a statistically significant difference and a substantial improvement in heartburn rates and overall symptomatic amelioration. No statistically significant differences were noted in the rates of regurgitation, gastroparesis, dysphagia, bloating, or abdominal pain between the groups.
Conclusion: Hiatal hernia is a complex condition associated with high recurrence rates, with the anterior aspect being the most frequent site of recurrence. Our study demonstrated that the placement of a 7 × 10 cm mesh using the keyhole technique, augmented anteriorly by positioning it beneath the left triangular ligament, provides enhanced structural support and reduces the recurrence rate of hiatal hernia.
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