Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Summary

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Abstract

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.

This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Introduction

The most recent meta-analysis review on para-esophageal hernia repair concluded that mesh reinforcement was superior and was associated with lower recurrence rates compared to the suture repair¹. However, the preferred type of mesh remains controversial due to the study heterogeneity. Some included in the review had inconsistent definitions not only of para-esophageal hernias (which were either determined pre-operatively or intra-operatively) or hernia recurrences (which were based, either on symptoms or investigations), but also unspecified loss to follow-up. This manuscript highlights successful repair of a large hiatus hernia using biosynthe....

Protocol

The protocol follows the guidelines of the authors’ institution’s human research ethics committee (South-Western Health District).

1. Pre-operative preparation

1. Place the patient on low calorie high protein nutritional diet for a week to reduce the liver size and facilitate improved access to the hiatus hernia.
2. Under general anesthesia, place the patient in lithotomy and reverse Trendelenburg position.
3. Intra-operatively, prescribe first-generation cephalosporin prophylactic (2 g) intravenous antibiotic and anticoagulation for deep vein thrombosis prophylaxis.

2. Sur....

Results

Post-operatively the patient remained symptom free. Routine gastroscopies at 4, 12 and 24 months respectively showed that the cardio-esophageal junction remained at 38 cm from the dental arcade with no evidence of early recurrence or reflux esophagitis. There was mild gastritis of the antrum.

This technique has been performed in 32 patients using absorbable biosynthetic mesh. Only one patient reported complication (Table 1).

Discussion

The key steps in para-esophageal hernia repair include port placement, total excision of the hernia sac, intra-abdominal esophageal lengthening, identification of both vagus nerves, atraumatic mesh reinforcement of the crus, and anterior fundoplication with gastroplasty.

This protocol highlights a 4-port method (one camera, three working ports) which uses only one assistant. Safe insufflation is achieved through a Veress needle inserted at Palmer’s point. An optical bladeless access syst.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
1.0 non-absorbable suture
10 mm port
3.0 absorbable suture
5mm port
Biosynthetic mesh	GORE BIO-A
Bladeless optical access entry system	Kii
Drain
Fibrin glue	Tiseel
Laparoscopic grasper	Ethicon
Laparoscopic harmonic  scalpel	Ethicon
Nathan liver retractor
Sling
Veress needle