Objective follow-up after laparoscopic repair of large type III hiatal hernia. Assessment of safety and durability.

Background: Symptomatic results of laparoscopic repair of large type III hiatal hernias, with/without prosthetic mesh, are often excellent; however, a high recurrence rate is detected when objective radiological/endoscopic follow-up is performed. The use of mesh may reduce the incidence of postoperative hernia recurrence or wrap migration in the chest.

Methods: We retrospectively studied 54 patients (10 men, 44 women; median: age 64.5 years) with a diagnosis of large type III hiatal hernia (>1/3 stomach in the chest on x-ray) who underwent laparoscopic repair at our department from January 1992 to June 2005. Complications, recurrences, and symptomatic and objective (radiological/endoscopic) long-term outcome were evaluated.

Results: Nineteen patients had laparoscopic Nissen/Toupet fundoplication with simple suture; in 35 patients a double mesh was added. The median radiological/endoscopic follow-up was 64 months (interquartile range (IQR): 6-104) for the non-mesh group and 33 (IQR:12-61) for the mesh group (p = 0.26). Recurrences occurred in 11/54 (20%) patients: 8/19 (42.1%) without mesh and 3/35 (8.6%) with mesh (p = 0.01). The 3 recurrences in the mesh group all occurred < or =12 months postoperatively; 4/8 recurrences in the non-mesh group occurred > or =5 years after operation. On multivariate logistic regression analysis, only mesh absence significantly predicted hernia recurrence or wrap migration.

Discussion: Laparoscopic repair of large type III hiatal hernias is safe and effective. Short-term symptomatic results are excellent, but mid-term objective radiological/endoscopic evaluation reveals a high recurrence rate. Possible reasons for failure of a laparoscopic hiatal repair are tension or poor muscle tissue characteristics in the hiatus. The use of a mesh, either by reducing tension or reinforcing muscle at the hiatus, might be associated with a lower recurrence rate. Longer-term follow-up will be needed before definitive conclusions can be drawn, however.