The use of mesh reinforcement for giant hiatal hernia repair is stilled among surgeons debates.
In my experience ; I don't think it's necessary. Partial gastrectomy
and gastropexy will be very effective procedure in these elderly and frail patients
who are the usual and classical patients for big hiatus hernia.
The reiforcment or not of the hiatus in the cure of giant hiatal hernia depend on multiples factors:-)
The importance of the defect in the hiatus
The quality of the the two diaphragmatic piliers
The elective or emergent surgey
The laparoscopic or classic approach is not important
Finally, the indication of the surgery, symptoatic Gerd, bleeding, volvolus
I think that the decision is made peroperatively but the surgeon must be aware about the necessity to put a mesh to reinforce the hital orifice
Preoparative management by endoscopic, transit and scan canpermit to appreciate the volume of the hernia, the type of it and the difficulty of descending the herna cone in the intra abdominal site which is thz peincipal factor to succes our cure.
Sure, I totally agree with you, even if i don't consider the partial gastrectomy to treat a gian hiatal hernia
Not necessarily as this depends on the duration and the state of the myoaponeurotic pillars after reduction of the hernia, so better to be juged case by case.
I think there are two opposing factors regarding the use of mesh for reinforcement of hiatal/paraesophageal hernia repair. Mesh has clearly been shown to reduce the recurrence rate of hernias, when compared to non-mesh repairs. However, there is a theoretical/anecdotal concern regarding the possibility of mesh erosion into the distal esophaghus/GE junction. Because of this, some have proposed the use of biologic mesh rather than synthetic mesh, but this has not, to my knowledge, been examined in a prospective trial.
My personal practice is to use mesh selectively. If there is no tension, I perform simple interrupted sutures to approximate the crura together. If there is some tension on the repair, I reinforce my sutures with teflon pledget "strips" on either side of the crura, placed on the lateral edges of each crura to avoid rubbing against the distal esophagus/GE junction. In cases of a larger hernias with a greater degree of tension on the hernia repair, I place a biologic mesh as an overlay to my repair.
I respectfully disagree with the suggestion of partial gastrectomy, gastropexy, or gastrostomy to assist in hiatal hernia repairs - these techniques have never been demonstrated to be beneficial.
I would agree that there is little place for partial gastrectomy in the management of uncomplicated giant hiatal hernia. I am fairly liberal with the use of mesh and would need to use this about 40 to 50% of very large hernias and favour TiMesh (with no real evidence that it is superior) on the basis that it handles well and is relatively easy to place. I employ this as an onlay after primarily approximating the hiatal pillars. With more than 90 repaired with mesh in this fashion and to my knowledge without erosion, I think this is a reasonable approach when confronted with tension on the repair.
Always a biological mesh reinforcement of the repaired haitus is necessary in giant hiatal hernias. Even with the use of mesh reinforcement the rate of radiological recurrence at 10 years exceeds 30% at least though most of the patients are asympotatic and won't necessarily need reoperation. I also disagree with partial gastrectomy, gastropexy etc. The laparoscopic repair of these gaints hernias is well within the remit of any upper GI lap surgeon
The mesh reinforcement is frequently (but surely not always) necessary during reconstruction of diaphragm for giant hiatal hernias. You need to judge the use of a mesh in every particular case.
However I am absolutely surprised to read that partial gastrectomy is a method for treatment of hiatal hernia?!? Am I missed something in my education?
Whether you believe in mesh or not (I personally have major concerns about its use near the Oesophagus) a mesh repair cannot be a substitute for a well performed extra sac approach, mobilising the Oesophagus into the abdomen and a good crural repair (always possible in my experience).
We have to accept that these are difficult procedures with a risk of recurrence. Most patients will have a small sliding HH if you look hard enough 5 years after surgery but compared to their initial para Oesophageal hernia this would still be considered good result
- Badges
- Science topic
- Similar topics
- Social Psychology
- Attitude