Influence of the size of the hiatus on the rate of reherniation after laparoscopic fundoplication and refundopilication with mesh hiatoplasty.

Background: Intrathoracic wrap migration is the most frequent morphological anatomic reason for failure of laparoscopic antireflux surgery (LARS). This study investigates whether the size of the esophageal hiatus is a factor in reherniation after LARS with mesh hiatoplasty and after primary failed hiatal closure.

Methods: Fifty-four patients who underwent a laparoscopic 270° Toupet fundoplication with simple sutured crura and posterior onlay of Parietex mesh prosthesis between October 2003 and June 2008 were evaluated with respect to the occurrence of postoperative intrathoracic wrap migration/reherniation. Indication for mesh hiatoplasty was a hiatus with a hiatal surface area (HSA) of at least 5.60 cm(2) or slippage after the first LARS. The integrity of repair was assessed using a barium swallow test. Cinematography was performed at a median of 25.6 months (3-63 months after operation) and was completed in 49 of 54 patients (90%). Follow-up was completed in 24 patients who underwent primary LARS (group A) and 25 patients who underwent a laparoscopic refundoplication (group B).

Results: In group A, the occurrence of postoperative wrap reherniation was diagnosed in 20.8% of the patients, compared to 40% in group B. In both groups only one patient with recurrent hiatal hernia was symptomatic. In group A, patients who developed a recurrent hernia had a larger HSA than patients without postoperative reherniation. There was a huge difference in the size of the HSA between symptomatic and asymptomatic patients with reherniation. In comparison, group B patients had HSA of similar size in all described cases.

Conclusion: In primary intervention, recurrence of hiatal hernia is more likely the larger the HSA is. The size of the hiatus is a major contributing factor to the possibility of reherniation. After failed primary hiatal closure, the size of the hiatal defect is no marker for the possibility of reherniation.