The polypropylene mesh in the laparoscopic repair of large hiatal hernias: technical aspects.

BACKGROUND The minimally invasive surgery has gained rapidly important role in the treatment of gastroesophageal reflux disease. However, the best method to treat large paraesophageal hernias (type III and IV) is still under discussion. The use of prosthetics for enhancing the crural repair has been proposed by several authors in order to reduce the high relapse rates found in these patients. AIM To demonstrate the technique and surgical results in using an idealized polypropylene mesh for the strengthening of the cruroraphy in large hiatal hernias. METHODS Was applied the polypropylene mesh to reinforce the hiatal closure in large hernias--types II to IV in Hill's classification--with a primary or recurrent hiatal defect greater than 5 cm, in a series of 70 patients. The prosthesis was done cutting a polypropylene mesh in a U-shape, adapted to the dimensions found in the intraoperative field and coating the inner edge (which will have direct contact with the esophagus) with a silicon catheter. This was achieved by removing a small longitudinal segment of the catheter and then inserting the edge of the cut mesh, fixing with running nylon 5-0 suture. RESULTS From 1999 to 2012, this technique was used in 70 patients. There were 52 females and 18 males, aged 32-83 years (mean 63 years). In 48 (68.6%) patients, paraesophageal hernia was primary and in 22 (31.4%), it was relapse after antireflux surgery. The only case of death in this series (1.4%) occurred on 22nd postoperative day in one patient (74 y) that had a laceration of the sutures on the fundoplication, causing gastropleural fistula and death. There was no relationship with the use of the prosthesis. A follow-up of six months or more was achieved in 60 patients (85.7%), ranging from six to 146 months (mean 49 months). All patients have at least one follow-up endoscopy or esophageal contrast examination, and a clinical interview. In this follow-up period, no cases of complications related to the prosthesis (stenosis or erosion) were observed. CONCLUSION The use of this model of polypropylene mesh is safe if the technical aspects of its placement are followed carefully.