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Mesh in the Hiatus
A Controversial Issue
Eduardo M. Targarona, MD, PhD;
Gali Bendahan, MD;
Carmen Balague, MD, PhD;
Jordi Garriga, MD;
Manuel Trias, MD, PhD
Arch Surg. 2004;139:1286-1296.
ABSTRACT
Objective To analyze the experience acquired to date on the use of prosthetic mesh to prevent recurrence after laparoscopic repair of paraesophageal hernia.
Data Sources Current English-language literature review.
Study Selection Case reports, series, and opinion articles on the use of mesh for paraesophageal hernia repair.
Data Extraction and Synthesis Study type and results were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the procedure have been published to date. The information available showed that the use of a mesh for hiatal repair was safe and prevented recurrence. However, data on the long-term results were lacking, and infrequent but severe complications may arise.
Conclusions The mesh should be used selectively, and the decision to proceed should be based on clinical experience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have not been confirmed.
INTRODUCTION
Success in the development of laparoscopic fundoplication has made this procedure a valid alternative to medical therapy for the treatment of gastroesophageal reflux. Thanks to the experience acquired, the laparoscopic approach is now used to treat more complex situations, such as paraesophageal hernia (PEH) or type III (mixed) hiatal hernia.1-8 The results of several series have shown that laparoscopic repair is also feasible and safe, despite the increased technical difficulty, and its immediate and short-term results are excellent9-43 (Table 1). However, the incidence of recurrences may be high: as much as 42% in one series (Table 2).
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Table 1. Results of Laparoscopic Repair of PEH (Series With More Than 20 Cases)
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Table 2. Recurrence After Surgical Treatment of PEH in Series With Systematic Radiologic Control
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One of the most demanding laparoscopic technical steps is crural closure, especially when the gap is wide and the closure inevitably entails a tension repair. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure44-66 (Table 3 and Table 4), but others argue against it. This review analyzes the experience accumulated so far on the use of mesh to reinforce the hiatus to prevent recurrence after laparoscopic repair of PEH.
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Table 3. Results of the Use of Mesh for PEH Repair
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Table 4. Results of Comparative Studies of PEH Repair
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THE PROBLEM
Laparoscopic repair of PEH and mixed hiatal hernias is a feasible, safe, but complex procedure. The experience during the past 15 years suggests that viscera reduction, sac excision, retrogastric crural closure, and fundoplication are the key technical factors.1-8 Fixation of the gastric plicature, abdominal wall gastropexy, and gastrostomy are more controversial technical steps for maintaining the stomach in place in the abdomen. Although controlled comparative trials with the open approach are lacking (Table 4), the immediate clinical outcome of laparoscopic PEH repair is highly satisfactory. However, the recurrence rate is higher than expected after midterm follow-up—as high as 42% when compared with the open approach66-95 (Table 5)—and some authors have suggested that the laparoscopic approach is unsuitable.17 The main reason for the failure of the hiatal repair is tension. Recurrence has been related to the mean diameter of the hiatus (>10 cm in some cases). Another factor is the anatomy of the pillars. The hiatal crus is a fleshy structure without tendinous reinforcement. Standard sutures may cut the muscle, and when the hiatus is particularly wide and the pillars are approached, the lateral portions of the diaphragm near the crura become tense, with a potential risk of disruption.
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Table 5. Results of the Open Approach for PEH Repair
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Currently, all hernia repairs are tension free (for example, the Lichtenstein repair or ventral hernia repair). However, performing a tension-free repair in the hiatus is technically very demanding, because of the oblique situation of the pillars and the difficulty of fixing the mesh. Furthermore, the hiatus is a complex anatomic structure in which the esophagus moves during respiratory excursion of the diaphragm,96 whereas in inguinal or ventral hernia repair the mesh passively supports the intra-abdominal viscera. This means that any prosthetic mesh will be in contact with the esophagus, and so there is a theoretical risk of esophageal erosion and complication. This fact—along with evidence of mechanical complications after placement of mesh for repair of abdominal wall defects and complications with mechanical devices located in the cardia (such as the Angelchik device97-99 and with the bands used in treatment of morbid obesity100)—seems to argue against the placement of foreign bodies in the hiatus. However, some surgeons report that the use of mesh in the hiatus is safe and the outcome acceptable (Table 3 and Table 4).
RECURRENCES
Analysis of recurrences shows different patterns for time of presentation and shape (Table 2). Immediate recurrent hernias are usually secondary to total disruption of the hiatal closure with a relapsing PEH. Long-term recurrences may adopt several patterns: complete recurrent PEH, fundoplication migration, or a small sliding hernia, without a clear recurrence of the paraesophageal sac. In the latter subgroup, the incidence of symptoms is variable, and most are identified only by esophagogram. Recurrences of symptoms are treated surgically. However, there is tacit agreement that nonsymptomatic recurrences, especially in cases of small sliding hernias, do not require repair. Recurrent hernias of any type should be considered as technical failures, although the long-term outcome of asymptomatic recurrent hernias is unknown.
METHODS
A systematic PubMed search looking for all of the studies published in English in relation to treatment of paraesophageal and mixed hiatal hernias was performed. Particular attention was paid to the use of meshes for reinforcement of the hiatal repair.
SURGICAL TECHNIQUE
The most controversial issue in the use of prostheses in the hiatus is the surgical technique. Several models have been proposed.
Tension-Free Techniques
One tension-free technique is anterior placement of a triangular piece of mesh, proposed by Paul et al52 (Figure 1). A triangular or semilunar polytef patch is placed to occlude the anterior segment of the hiatus and fixed with staples or stitches. The stomach is fixed to the abdomen and a fundoplication is added.
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Figure 1. Tension-free repair: anterior placement of a triangular piece of mesh.39
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For posterior placement of a triangular piece of mesh (Figure 2), the aim is the same as in the technique for anterior placement. Kuster and Gilroy46 proposed a posterior segmental occlusion, occluding the base of the pillar overture, and placing the esophagus anteriorly, fixing the mesh with staples or stitches. Fixation to the abdominal wall or a gastrostomy is also performed.
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Figure 2. Tension-free repair: posterior placement of a triangular piece of mesh.46
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A third technique involves onlay of a piece of mesh, with a hole facilitating the passage of the esophagus. The mesh covers the whole of the hiatal defect, and no attempt is made to close the hiatus (Figure 3). There are several shapes of mesh designed to allow the passage of the esophagus and to facilitate fixation (eg, U shape,22, 53 A shape59) (Figure 4). Basso et al101 also proposed covering the mesh with autologous flaps of peritoneal tissue obtained from the hernia sac. Casaccia et al59 recently proposed a composite polytef-polypropylene A-shaped mesh. This mesh was designed according to the strength lines of the hiatus and produced good results after 8 months of follow-up.
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Figure 3. Tension-free repair: onlay piece of mesh, with a hole facilitating the passage of the esophagus.
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Figure 4. Shapes of mesh designed to allow passage of the esophagus and to facilitate fixation (U shape,22, 53 A shape59).
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A piece of mesh may be placed just covering the defect below the esophagus, overlapping both pillars laterally. This was described by Basso et al56 (Figure 5).
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Figure 5. Tension-free repair: piece of mesh just covering the defect below the esophagus, overlapping both pillars laterally.56
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In another technique, after a standard closure of the hiatus, a relaxing incision lateral to the right crura is placed, and a patch is fixed with stitches or staples covering the diaphragmatic defect (Figure 6). Described by Huntington in 1997,51 it has been also proposed by Horgan et al.15
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Figure 6. Tension-free repair. After a standard closure of the hiatus, a relaxing incision lateral to the right crura is performed, and a patch is fixed with stitches or staples covering the diaphragmatic defect.15, 51
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Non–Tension-Free Techniques
Simple crural closure with either simple stitches (Figure 7) or a continuous suture (Figure 8) is the most common method for hiatal closure. In 1992, Cuschieri et al102 described the first specific method for hiatal closure, using a continuous suture.
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Figure 7. Non–tension-free repair: simple crural closure with simple stitches.
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Figure 8. Non–tension-free repair: simple crural closure with continuous suture.102
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Other non–tension-free techniques are reinforcement of the crural closure, to avoid the cutting effect of the stitches; simple stitches with Teflon or Dacron pledgets18, 29 (Figure 9); a polypropylene strip along the crura to hold the stitches (Figure 10); and a piece of polypropylene mesh covering both edges of the pillars. The stitches close the hiatus including the mesh and tissue, as proposed by Kamolz et al60 (Figure 11).
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Figure 9. Non–tension-free repair with reinforcement of the crural closure to avoid the cutting effect of the stitches, using simple stitches with Teflon or Dacron pledgets.18, 29
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Figure 10. Non–tension-free repair with reinforcement of the crural closure, using a polypropylene strip along the crura to hold the stitches.
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Figure 11. Non–tension-free repair with reinforcement of the crural closure, using a polypropylene piece of mesh covering both edges of the pillars.60
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A buttress mesh technique has also been described. A long strip of mesh is placed below the esophagus, covering the pillar closure (Figure 12). The advantage is that it avoids the encircling of the esophagus, reducing the risk of dysphagia or erosion. Champion and Rock61 reported good results in a series of 52 cases, with a recurrence rate of 2%, although esophagography was performed in only 52% of cases.
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Figure 12. Non–tension-free repair with reinforcement of the crural closure using buttress mesh. A long strip of mesh is placed below the esophagus, covering the pillar closure.61
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Placement of onlay mesh around the esophagus with a hole in the middle, once the defect has been closed, has been used (Figure 13). There are also preshaped meshes designed to adapt anatomically to the characteristics of the anatomic area31, 62 (Figure 4).
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Figure 13. Non–tension-free repair with reinforcement of the crural closure. Onlay mesh is placed around the esophagus once the defect has been closed.31, 62
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Other Maneuvers
Additional maneuvers for fixing the stomach in the abdominal cavity include a range of techniques, such as fixation of the fundoplication to the diaphragm, fixation of the gastric body to the abdominal wall, and gastrostomy.103-104 Fundoplication itself may have some fixation effect. Some authors have proposed that the Toupet technique may avoid recurrence because the posterior placement of the fundus covers the crural closure and fixes it to the diaphragm.1, 3 However, there are no definitive data from randomized trials to support any of these measures.
REPAIR MATERIAL
The prostheses available for hiatal reinforcement are made of a range of materials. Most authors agree that the material used should be nonresorbable, because resorbable material (poly-glycolic acid) loses its mechanical properties as it is resorbed. Nonresorbable material may be made of polypropylene, polytef, or composite (polytef plus polypropylene; C. R. Bard, Inc, Murray Hill, NJ). Recently, a nonresorbable material of biological origin has been used (Surgisis; Cook Biotech Incorporated, West Lafayette, Ind).62 The crucial aspect of the material used to reinforce the hiatus is stiffness. The advantages of polytef are its softness and its lower capacity to induce adhesions. The different surfaces prevent tight adhesions to the visceral face of the mesh, and the texture of the free margin in near contact with the esophagus is potentially less dangerous. However, the handling and sewing of the mesh may be more difficult than when polypropylene is used. The main drawback of polypropylene is the stiffness of the margins and the possibility that the esophagus will be eroded. Experience with mixed mesh or with material of biological origin is scarce.
RESULTS
Most of the clinical results of the use of mesh in the hiatus come from short series of patients, although the midterm follow-up is often adequate (up to 5 years). No long-term experience (up to 10 years) is available. Mesh has been used mostly in adults, although there is some experience in the pediatric setting as well. Overall results are plotted in Table 2; tolerance is good and the recurrence rate and morbidity are both low. Three comparative studies have been published (Table 3), but only 1 was a prospective randomized trial. In addition, 2 of the comparative trials included patients with all types of hiatal hernias, and only 1 focused on PEH hernia repair. Basso et al56 compared simple and tension-free closures using an onlay piece of polypropylene, dividing their personal series chronologically into 2 parts. Kamolz et al60 compared simple closure with a reinforcement procedure that put the stitches over a piece of polypropylene covering the hiatal closure. Neither study was randomized; they were merely comparisons of initial experiences without mesh with more recent experiences with mesh. They also counted hiatal repair of all types, including type I hernias or pure gastroesophageal reflux disease without hernia. Mesh placement was followed by reductions in the incidence of recurrences, without specific morbidity.
Frantzides et al65 showed the results of a prospective randomized trial comparing simple closure with polytef onlay reinforcement for PEH hernia repair, in cases with hiatus wider than 8 cm. Recurrences were significantly reduced after mesh placement (20% vs 0%; P<.001), without long-term sequel, after a 40-month follow-up period.
The main drawback with the use of mesh in the hiatus is the risk of local complications (fibrosis and adhesions, erosion, or perforation). Nonetheless, the incidence of mesh-related complications in the hiatus is currently less than 2%, although no reports on long-term outcome (>10 years) are available.
Mesh placed in the hiatus may induce complications because of the type of mesh or the device used for fixation. Some complications may be related to local fibrosis (dysphagia) or to the erosion of the digestive lumen. Others may be induced by the device applied to fix the mesh, especially when staples or tackers are used, and injury to the vital structures surrounding the hiatus may occur. Teflon pledgets may also erode the fundus or induce fibrous retraction and dysphagia. Table 6 shows the incidence of complications of this type in reports published to date.105-108 Mesh has also been used in pediatric cases, without long-term problems.52, 109
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Table 6. Complications in Relation to Prosthesis Placement for Surgical Repair of Hiatal Hernia
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COMMENT
Surgical treatment of PEH and type III mixed hernias has been a challenging chapter in digestive surgery for the past 30 years (Table 4). The treatment used to be offered to a subset of elderly patients, some of them particularly frail and, in some cases, associated with urgent situations such as gastric volvulus or gastric incarceration. However, the results from centers with wide experience showed low morbidity and good long-term outcome after standard open transthoracic or transabdominal approaches, although in most series the results were merely assessed on the basis of the presence or absence of symptoms without any anatomic (radiologic) evaluation.110 The experience available shows the efficacy of the laparoscopic approach for treatment of PEH.111-112 Despite the increased intraoperative technical difficulty, and although there are no comparative randomized trials with the open approach to conclusively determine their relative merits, the immediate outcome clearly endorses this minimally invasive approach in a population that is typically at higher risk than conventional patients with GERD or small type I hiatal hernia. The large number of series published in recent years (20 series related to the open approach in 33 years, compared with 46 series in 12 years for the laparoscopic approach) bears witness to the success of, and the interest in, the application of laparoscopic techniques in PEH repair.
Most accepted technical rules for the surgical treatment of PEH include stomach reduction, sac excision, and closure of the hiatal defect—on occasion more than 8 cm wide—with or without the addition of some type of fixation. The controversy arises after the definitive observation of a variable recurrence rate (up to 42%) when a routine radiologic follow-up is done. Some authors have suggested that alternative approaches (open or thoracic) may be better for this disease. Arguments put forward to account for this unacceptably high recurrence rate include the learning curve due to the technical difficulty of the procedure, poor technical crural closure, or a short esophagus. The learning curve for a difficult laparoscopic procedure undoubtedly plays a role, and it has been observed in several large series that the recurrence rate falls as surgeons gain experience. The significance of a short esophagus continues to be a controversial issue. It has been considered as a potential cause of failure, but most patients with PEH do not have advanced gastroesophageal reflux disease with esophageal scarring. The need to perform a Collis gastroplasty to lengthen the esophagus varied from 0% to 70% in the series analyzed, and as yet there is no clear agreement on whether this technical step is needed during PEH repair.
Clearly, as with other abdominal wall defects, the aim is to achieve adequate closure. In contrast to the accepted standard concept for inguinal or ventral hernia, which is tension free, the most widely supported approach is to close the hiatus under tension, with the obvious risk of disruption. The rationale for this judgment is that, unlike the abdomen or groin, in which the aim of repair is to achieve passive containment, the cardial region including the hiatus and the gastroesophageal junction is a highly dynamic anatomic area and so anatomic repair is justified. However, since PEH repair causes wide-ranging anatomic distortion and the risk of disruption is high, reinforcement with mesh is a logical forward step. Hiatal closure is occasionally difficult. Surgeons who are in general against the placement of mesh in the hiatus are sometimes obliged to use the procedure to correct the defect, because of either the size of the defect or the technical impossibility of proceeding otherwise.
There are no clear reasons for the differences in outcome after open or laparoscopic approach to PEH. Possibly the final results of laparoscopic repair are not as good because the laparoscopic approach is more technically demanding. However, systematic evaluation with radiologic esophagogram, including asymptomatic patients, has shown a higher number of recurrences. Haas et al75 found an anatomic recurrence rate of 42% after systematic radiologic evaluation. This suggests that the problem may also have been evident in the open-procedure era, but has only become relevant today since the increase in laparoscopic procedures and the possibility of more detailed study.
One of the main arguments against mesh placement has been the emergence of complications due mainly to visceral erosion, a risk that is intrinsically related to the existence of a foreign body. On the basis of this rationale, many surgeons consider routine placement contraindicated. However, there are clear differences between the placement of mesh and insertion of an Angelchik device or bands used for gastric banding in obese patients. The latter devices are placed directly over the cardia, maintaining a sustained and continued tension and favoring potential erosion; in contrast, mesh in the hiatus for reinforcement of the diaphragmatic closure is placed outside the esophagus and direct contact is avoided. Although several serious complications have been reported, the morbidity rate associated with mesh placement is low (Table 6).
No objective information is available to guide the choice of material. Most authors prefer soft materials with less intense fibrotic response such as polytef rather than polypropylene, but no comparative trials of the materials have been performed. Complications have been reported with the use of both types of mesh. No long-term follow-up data on this issue are available; experience with other types of material such as combined mesh types or biomaterials is limited, and the follow-up periods are short.
Another controversial point is whether the use of mesh for hiatal repair in PEH should be routine or selective. The local conditions of the hiatus after sac excision may cause differences in the results, and sometimes, although the hernia sac is large, the pillars are of good quality and can be approached without difficulty. There are no studies investigating predictive factors for recurrence after laparoscopic repair of PEH, which may involve the anatomic features of the hiatus (such as the size of the gap, tension, or diaphragmatic weakness), the type of repair (single stitches, pledget, etc), additional fixation maneuvers (Toupet, fixation, gastrostomy, etc), and patient characteristics (heavy work, constipation, chronic cough, etc). Some authors recommend a tailored approach, placing a mesh in cases at major risk of recurrence, and its use seems more advisable in the case of reoperations. However, the decision clearly depends on the experience of the surgeon.
The final answers to our questions should come from analysis of the long-term follow-up over 5 years of series of patients in whom mesh has been placed, and randomized trials of suitable design to provide answers regarding the controversial technical aspects (type of mesh, location, selective vs routine, additional maneuvers [fixation], Collis esophageal lengthening, etc).
At present, the information available shows that the use of a mesh for hiatal repair after laparoscopic repair of PEH is safe and prevents hernia recurrence. However, information on the long-term results is lacking; severe complications may arise, albeit infrequently. A selective use based on clinical experience is recommended, as the technique appears to be safe, and the fears expressed at earlier stages of its development have not been confirmed.
AUTHOR INFORMATION
Correspondence: Eduardo M. Targarona, MD, PhD, Service of Surgery, Hospital de Sant Pau, Padre Claret 167, 08025 Barcelona, Spain (etargarona{at}hsp.santpau.es).
Accepted for Publication: January 19, 2004.
Acknowledgment: Isabel Salgado drew the illustrations for the figures in this article.
Author Affiliations: Service of Surgery, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
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