Laparoscopic tension-free repair of large paraesophageal hiatal hernias with a composite A-shaped mesh: two-year follow-up.

Background: Surgical repair of large hiatal hernias is associated with a high recurrence rate when the repair is made by simple cruroplasty. The use of a mesh goes from a reinforcement of a simple cruroplasty to a tension-free repair. We discuss the evolution of this approach and evaluate the outcomes of 27 patients with type II (n 9), type III (n 16), and type IV (n 2) hiatal hernias treated laparoscopically. Methods: Between November 1999 and October 2003, 27 patients (18 women and 9 men) received laparoscopic repair of large hiatal hernias by means of an A-shaped polypropylene-polytetrafluoroethylene mesh. A total or a partial fundoplication was associated in all cases. The mean age was 60.1 years (range, 36–76 years). The patients presented with symptoms of 2 months to 10 years duration. Preoperative assessment included an upper gastrointestinal endoscopy, esophageal manometry, 24 hour pH monitoring, and barium swallow. Concomitant esophagitis was found in 16 patients and impaired esophageal peristalsis in 2 patients. Four patients had concomitant gallbladder disease treated at the same time. Results: No conversions occurred in our series. There was no perioperative mortality, and morbidity was low. Follow-up averaged 27 months (range, 6–46 months). There has been 1 recurrence (3.7%), prolonged dysphagia in 4 cases, and no mesh erosion. Conclusion: Early results confirm the feasibility of the tension-free repair of large hiatal hernias and the effectiveness of the composite A-shaped mesh. Long-term follow-up for all patients is necessary to determine the real incidence of recurrence.