M Morino1, C Giaccone, L Pellegrino, F Rebecchi. 1. Department of Surgery, Minimally Invasive Surgery Center, University of Turin, C.so A.M. Dogliotti, 14, 10126 Torino, Italy. mario.morino@unito.it
Abstract
BACKGROUND: The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. METHODS: In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. RESULTS: There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. CONCLUSIONS: To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.
BACKGROUND: The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. METHODS: In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. RESULTS: There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. CONCLUSIONS: To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.
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