Laparoscopic revisional fundoplication with circular hiatal mesh prosthesis: the long-term results.

BACKGROUND: Failure of hiatal closure has proven to be the most frequent complication leading to revisional surgery after primary failed open or laparoscopic antireflux surgery. To prevent hiatal hernia recurrence some authors recommend the use of prosthetic meshes for reinforcement of the hiatal crura. The aim of the present prospective study was to evaluate the safety and effectiveness of a circular hiatal onlay mesh prosthesis applied during laparoscopic refundoplication after primary failed antireflux surgery with intrathoracic wrap migration. The follow-up period was 5 years.
METHODS: A total of 33 patients underwent laparoscopic refundoplication for recurrent symptoms of gastroesophageal reflux disease after primary failed laparoscopic or open antireflux surgery. The underlying morphological complication for symptom recurrence in all patients was hiatal hernia recurrence with intrathoracic migration of the fundoplication. During revisional surgery, after breakdown of the former fundoplication, the esophageal hiatus was thoroughly revised and a circular polypropylene mesh was used to buttress the primarily simple sutured hiatal crura. Additionally, in all patients a refundoplication was performed. Recurrences, complications, functional data, esophagogastroduodenoscopy, and cinematographic X-ray results, as well as quality of life data, were evaluated for the 60-month follow-up period.
RESULTS: All reoperations were successfully completed laparoscopically. Twenty-one patients underwent laparoscopic 360 degrees "floppy" Nissen refundoplication, and 12 patients underwent laparoscopic 270 degrees Toupet refundoplication. Hiatal closure was performed by placing a circular polypropylene sheet that had a 3-4 cm keyhole for the esophageal body. Of 24 patients who underwent redo-surgery before May 2000, no patient developed a recurrent hiatal hernia during the first 12 postoperative months. All 33 patients were re-evaluated and underwent complete diagnostic work-up over a follow-up period of 60 months postoperatively. During the long-term follow-up, a new recurrent hiatal hernia with intrathoracic wrap migration developed in 2 patients (6%). In both cases, slippage occurred anteriorly to the esophagus. Both patients were scheduled for repeat refundoplication. In all other patients no recurrence occurred for the complete follow-up period, and no mesh-related complications developed.
CONCLUSIONS: Laparoscopic refundoplication for primary failed hiatal closure with the use of a circular mesh prosthesis is a safe and effective procedure to prevent hiatal hernia recurrence for short- and mid-term follow-up. However, for long-term follow-up, even with the placement of prosthetic mesh, re-recurrence occurs in some patients, leading to repeated surgery.