Emanuele Asti, MD, FACS, Andrea Lovece, MD, Luigi Bonavina, MD, FACS

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Emanuele Asti, MD, FACS, Andrea Lovece, MD, Luigi Bonavina, MD, FACS Laparoscopic repair of large paraesophageal hernia: Comparison of mesh and suture cruroplasty Emanuele Asti, MD, FACS, Andrea Lovece, MD, Luigi Bonavina, MD, FACS Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School Background. Laparoscopic repair of large mixed and paraesophageal hiatal hernia is associated with high recurrence rate. The use of a prosthetic mesh to reinforce the hiatus can potentially decrease the recurrence rates but it may also cause dysphagia and visceral erosion. Results. From October 2009 to October 2014, a total of 84 patients, 41 in group A and 43 in group B, were included in the study. All surgical procedures were completed laparoscopically. The mean follow-up was 36+8 months. The recurrence free probability was similar in the two groups (p=0.216). However, an earlier failure rate was noted in group B at 12 months. Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may potentially reduce the recurrence rate. No mesh-related complications occurred throughout the follow-up. Objectives. To evaluate the objective and subjective outcome of a cohort of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh (BIO-A®) augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy and long-term quality of life. Methods. Observational cohort study. Patients who underwent laparoscopic repair of large (≥5cm) type II and III hiatal hernia and had a minimum 1-year follow-up were included. Criteria of exclusion were previous or concomitant surgical procedures at the esophago-gastric junction. Patients were stratified into group A (mesh augmented (BIO-A®) crura repair and Toupet/Nissen fundoplication), and group B (standard crura repair and Toupet/Nissen fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12 months postoperatively, and was repeated over the follow-up every 1-2 years or as needed. Anatomical hernia recurrence was defined as the maximum measured vertical height of stomach being at least 2 cm above the diaphragm. Conclusions. Laparoscopic repair of large hiatal hernia is effective and durable over time. Reinforcement of crura repair with a resorbable synthetic mesh is safe and may protect from early anatomical recurrences.