Laparoscopic repair of hiatal hernias: new classification supported by long-term results.

BACKGROUND: Mesh repair may decrease the recurrence rate but bears risk of esophageal complications. This study aimed to analyze the long-term results of laparoscopic hiatal repair depending on hiatal surface area (HSA).
METHODS: The results from 658 procedures were analyzed. Group 1 had 343 patients with HSA smaller than 10 cm(2) (small hernias), for whom primary crural repair was performed. Group 2 had 261 patients with HSA size 10-20 cm(2) (large hernias), for whom primary crural repair (subgroup A) or mesh repair (subgroup B) was performed. Group 3 had 54 patients with HSA larger than 20 cm(2) (giant hernias), for whom only mesh repair was performed.
RESULTS: The mean follow-up period was 28.6 months (range, 10-48 months). Primary repair results in a higher recurrence rate for large hernias (11.9 %) than for small hernias (3.5 %) (p = 0.0016). For large hernias, the original method of sub-lay lightweight partially absorbable mesh repair provides a lower recurrence rate than primary repair (4.9 % vs 11.9 %; p = 0.0488) and a comparable dysphagia rate (2.1 % vs 2.2 %; p = 0.6533). For giant hernias, mesh repair results in a higher recurrence rate than for large hernias (20 % vs 4.9 %; p = 0.0028). The analysis of variance (ANOVA) HSA recurrence ratio confirmed the correctness of the chosen threshold levels (10 and 20 cm(2)) for subdividing hernias into three classes according to the new classification.
CONCLUSIONS: The authors advise routine measurement of HSA and use of relative classification, primary suturing as the optimal repair for small hernias, the original technique of sub-lay lightweight partially absorbable mesh repair as the apparent best treatment for large hernias, and the original technique for giant hernias, which provides results corresponding to those reported in the literature, although these results require improvement.