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Mesh in the Hiatus: a Controversial Issue REVIEW ARTICLE 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 Objective: To analyze the experience acquired to date cedure have been published to date. The information avail- on the use of prosthetic mesh to prevent recurrence af- able showed that the use of a mesh for hiatal repair was ter laparoscopic repair of paraesophageal hernia. safe and prevented recurrence. However, data on the long- term results were lacking, and infrequent but severe com- Data Sources: Current English-language literature re- plications may arise. view. Conclusions: The mesh should be used selectively, and Study Selection: Case reports, series, and opinion ar- the decision to proceed should be based on clinical ex- ticles on the use of mesh for paraesophageal hernia repair. perience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have Data Extraction and Synthesis: Study type and re- not been confirmed. sults were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the pro- Arch Surg. 2004;139:1286-1296 UCCESS IN THE DEVELOPMENT THE PROBLEM of laparoscopic fundoplica- tion has made this procedure a valid alternative to medical Laparoscopic repair of PEH and mixed hi- therapy for the treatment of atal hernias is a feasible, safe, but complex gastroesophageal reflux. Thanks to the ex- procedure. The experience during the past S 15 years suggests that viscera reduction, perience acquired, the laparoscopic ap- proach is now used to treat more complex sac excision, retrogastric crural closure, situations, such as paraesophageal hernia and fundoplication are the key technical 1-8 (PEH) or type III (mixed) hiatal hernia.1-8 factors. Fixation of the gastric plicature, The results of several series have shown that abdominal wall gastropexy, and gastros- laparoscopic repair is also feasible and safe, tomy are more controversial technical despite the increased technical difficulty, steps for maintaining the stomach in place and its immediate and short-term results in the abdomen. Although controlled are excellent 9-43 (Table 1). However, the comparative trials with the open approach incidence of recurrences may be high: as are lacking (Table 4), the immediate clini- much as 42% in one series (Table 2). cal outcome of laparoscopic PEH repair is highly satisfactory. However, the recur- See Invited Critique rence rate is higher than expected after midterm follow-up—as high as 42% when on page 1296 compared with the open approach 66-95 (Table 5)—and some authors have sug- One of the most demanding laparo- gested that the laparoscopic approach is scopic technical steps is crural closure, es- unsuitable.17 The main reason for the fail- pecially when the gap is wide and the clo- ure of the hiatal repair is tension. Recur- sure inevitably entails a tension repair. Some rence has been related to the mean diam- authors recommend the use of prosthetic eter of the hiatus (Ͼ10 cm in some cases). mesh to reinforce the hiatal closure 44-66 Another factor is the anatomy of the pil- (Table 3 and Table 4), but others argue lars. The hiatal crus is a fleshy structure Author Affiliations: Service of against it. This review analyzes the expe- without tendinous reinforcement. Stan- Surgery, Hospital de Sant Pau, rience accumulated so far on the use of dard sutures may cut the muscle, and Autonomous University of mesh to reinforce the hiatus to prevent re- when the hiatus is particularly wide and Barcelona, Barcelona, Spain. currence after laparoscopic repair of PEH. the pillars are approached, the lateral (REPRINTED) ARCH SURG/ VOL 139, DEC 2004 WWW.ARCHSURG.COM 1286 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 1. Results of Laparoscopic Repair of PEH (Series With More Than 20 Cases) No. (%) No. (%) Mean Mean Good or Mesh Source N Conversion Morbidity MortalityStay, d Follow-up, mo Recurrence Fair Outcome Used Comment Huntington,9 1997 58 1 (2) 4 (7) 0 2.8 12 0 NA Occ SE + ACR + FP Perdikis et al,10 1997 65 2 (3) 9 (14) 0 2 18 20 (13) 60 (92) 0 PCR + FP Edye et al,11 1998 58 3 (5) 10 (17) 1 (2) NA 38 8 (14) NA 1 (2) SE + PCR + FP Gantert et al,12 1998 55 5 (9) 5 (9) 1 (2) 3 11 NA 50 (91) 0 SE + PCR + FP Watson et al,13 1999 86 20 (23) 11 (13) NA 3 24 1 (1) 80 (93) 0 SE + PCR + FP Wu et al,14 1999 38 1 (3) 6 (16) 2 (5) 3 3 9 (24) 30 (79) 5 (13) Several repairs Horgan et al,15 1999 41 2 (5) 1 (2) 1 (2) 4 36 5 (12) NA Occ SE + PCR + FP Swanstrom et al,16 1999 52 0 6 (12) 0 3 18 4 (8) NA NA SE + PCR + FP Hashemi et al,17 2000 26 2 (8) 3 (12) 0 3 17 NA 20 (77) 0 SE + PCR + FP Peet et al,18 2000 22 3 (14) 1 (5) 0 NA 24 5 (22) NA 3 (14) SE + PCR + FP + fixation Dahlberg et al,19 2001 37 2 (5) 5 (14) 2 (5) 4 15 5 (14) 32 (87) Occ SE + PCR + FP Wiechmann et al,20 2001 60 6 (10) 1 (2) NA NA 19 4 (7) NA 0 SE + PCR + FP Velanovich and 31 5 (16) 3 (10) 1 (3) NA 24 NA NA NA Several repairs Karmy-Jones,21 2001 Khaitan et al,22 2002 31 6 (19) 6 (19) 0 2.9 25 12 (40) NA NA SE + PCR + FP Pierre et al,23 2002 203 3 (1.5) 57 (28.1) 1 (0.5) 3 18 4 (2.0) 170 (83.7) 22 (10.8) SE + PCR + collis Mattar et al,24 2002 136 3 (2.2) 14 (10.3) 3 (2.2) 4 40 41 (30.1) NA 0 Several repairs Diaz et al,25 2003 116 3 (2.6) 20 (17.2) 2 (1.7) 2 30 37 (31.9) 9 (7.8) Occ SE + PCR + FP + fixation Targarona et al,26 2004 46 0 0 NA 4 30 NA NA NA None Leeder et al,27 2003 53 4 (8) 7 (13) 1 (2) 2 46 5 (9) 41 (77) 14 (26) Several repairs Ponsky et al,28 2003 28 0 3 (11) 0 2 21 0 1 (4) NA PCR + Toupet + fixation Jobe et al,29 2002 56 4 (7) 11 (20) 0 2.6 39 18 (32) 45 (80) 6 (11) Hill repair Keidar and Szold,30 2003 33 1 (3) 5 (15) 1 (3) 3 58 5 (15) 28 (84) 28 (30) SE + PCR + FP Range (0-23) (0-28) (0-5.4) 2-4 (0-40) (77-94) (0-30) Abbreviations: ACR, anterior crural repair; FP, fundoplication; NA, not available; Occ, occasionally; PCR, posterior crural repair; PEH, paraesophageal hernia; SE, sac excision. Table 2. Recurrence After Surgical Treatment of PEH in Series With Systematic Radiologic Control No. (%) of Patients Recurrence, Symptoms, Source With Esophagogram No. (%) PEH Recurrence, No. Sliding, No. No. (%) Mesh Type Open Surgery Luostarinen et al,44 1998 19/22 (86) 8 (42) 4 4 7 (37) ±Pledget Laparoscopy Wu et al,14 1999 35/38 (92) 8 (23) 2 5 12 (34) NA Hashemi et al,17 2000 21/27 (78) 9 (43) NA NA 8 (38) Pledget Wiechmann et al,20 2001 44/60 (73) 3 (7) 3 0 44 (100) NA Khaitan et al,22 2002 15/25 (60) 6 (40) 1 5 8 (50) Pledget Jobe et al,29 2002 34/52 (65) 11 (32) 8 3 22 (65) Pledget Ͼ4cm Mattar et al,24 2002 32/125 (26) 11 (34) NA NA 14 (44) Pledget Keidar and Szold,30 2003 NA 21 (15) 0 5 13 (40) NA Diaz et al,25 2003 66/96 (69) 21 (32) 7 14 41 (62) NA Tagarona et al,26 2004 30/37 (81) 6 (20) 1 5 15 (50) NA Abbreviations: NA, not available; PEH, paraesophageal hernia. portions of the diaphragm near the crura become tense, cera. This means that any prosthetic mesh will be in con- with a potential risk of disruption. tact with the esophagus, and so there is a theoretical risk Currently, all hernia repairs are tension free (for ex- of esophageal erosion and complication. This fact—along ample, the Lichtenstein repair or ventral hernia repair). with evidence of mechanical complications after place- However, performing a tension-free repair in the hiatus is ment of mesh for repair of abdominal wall defects and com- technically very demanding, because of the oblique situa- plications with mechanical devices located in the cardia tion of the pillars and the difficulty of fixing the mesh. Fur- (such as the Angelchik device97-99 and with the bands used thermore, the hiatus is a complex anatomic structure in in treatment of morbid obesity100)—seems to argue against which the esophagus moves during respiratory excursion the placement of foreign bodies in the hiatus. However, some of the diaphragm,96 whereas in inguinal or ventral hernia surgeons report that the use of mesh in the hiatus is safe repair the mesh passively supports the intra-abdominal vis- and the outcome acceptable (Tables 3 and 4). (REPRINTED) ARCH SURG/ VOL 139, DEC 2004 WWW.ARCHSURG.COM 1287 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 3. Results of the Use of Mesh for PEH Repair No.
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