Name: laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh
Uploaded: 2021-09-11T13:00:00
Description: Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

The authors have no acknowledgements.

The protocol follows the guidelines of the authors&#8217; institution&#8217;s human research ethics committee (South-Western Health District).
1. Pre-operative preparation
<ol>
	<li>Place the patient on low calorie high protein nutritional diet for a week to reduce the liver size and facilitate improved access to the hiatus hernia.</li>
	<li>Under general anesthesia, place the patient in lithotomy and reverse Trendelenburg position.</li>
	<li>Intra-operatively, prescribe first-generation cep...

<ol>
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C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+systematic+review+of+laparoscopic+port+site+hernias+in+gastrointestinal+surgery.">A systematic review of laparoscopic port site hernias in gastrointestinal surgery.</a> Surgeon. 9 (4), 218-224 (2011).</li><li>Kohn, G. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+management+of+hiatal+hernia.">Guidelines for the management of hiatal hernia.</a> Surgical Endoscopy. 27 (12), 4409-4428 (2013).</li><li>Luketich, J. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+repair+of+giant+paraesophageal+hernia:+100+consecutive+cases.">Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases.</a> Annals of Surgery. 232 (4), 608-618 (2000).</li><li>Wiechmann, R. 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The key steps in para-esophageal hernia repair include port placement, total excision of the hernia sac, intra-abdominal esophageal lengthening, identification of both vagus nerves, atraumatic mesh reinforcement of the crus, and anterior fundoplication with gastroplasty.
This protocol highlights a 4-port method (one camera, three working ports) which uses only one assistant. Safe insufflation is achieved through a Veress needle inserted at Palmer&#8217;s point. An optical bladeless access syst...

The most recent meta-analysis review on para-esophageal hernia repair concluded that mesh reinforcement was superior and was associated with lower recurrence rates compared to the suture repair1. However, the preferred type of mesh remains controversial due to the study heterogeneity. Some included in the review had inconsistent definitions not only of para-esophageal hernias (which were either determined pre-operatively or intra-operatively) or hernia recurrences (which were based, either on symptoms or investigations), but also unspecified loss to follow-up. This manuscript highlights successful repair of a large hiatus hernia using biosynthetic mesh.
The most common biosynthetic mesh used is composed of 67% polyglycolic acid and 33% trimethylene carbonate. This prosthesis is gradually absorbed over 6 months and is replaced by the vascularized soft tissue and collagen. This biosynthetic mesh has been studied in 395 patients and in this large study, 16.1% of them experienced recurrent symptoms at 24 months (range, 2-69 months) and 7.3% had objective recurrence2. Only one patient had a major post-operative complication (esophageal stenosis) that required percutaneous endoscopic gastrostomy tube insertion and subsequently, re-operation with no recurrence at 44 months. Similar smaller studies reported symptom recurrence rates ranging from 0%-9%, objective recurrence rates 0.9%-25%, and re-operations ranging from 0%-10%4,5,6,7,8. None of the studies reported mesh-related complications.
The protocol detailed below was performed on a 68-year-old female who presented with a one-year history of severe reflux symptoms unresponsive to medical treatment and iron deficiency anemia, in the setting of previous Helicobacter pylori gastritis and NSAID-induced gastric ulcer. Pre-operative gastroscopy demonstrated Cameron&#39;s ulcers, large linear erosions in the gastric body and a 10 cm rolling hiatus hernia (compared to 4 cm in the previous gastroscopy one year earlier). Chest CT-scan confirmed the diagnosis of intra-thoracic para-esophageal hernia.

<table border="0" cellpadding="0" cellspacing="0" style="width:683px;" width="684">
	<tbody>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">1.0 non-absorbable suture</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td style="width:171px;"></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">10 mm port</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">3.0 absorbable suture</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">5mm port</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Biosynthetic mesh</td>
			<td style="width:125px;">GORE BIO-A</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:221px;">Bladeless optical access entry system</td>
			<td style="width:125px;">Kii</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Drain&#160;</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Fibrin glue</td>
			<td style="width:125px;">Tiseel</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Laparoscopic grasper</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Laparoscopic harmonic&#160; scalpel</td>
			<td style="width:125px;">Ethicon</td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Nathan liver retractor</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Sling</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:221px;">Veress needle</td>
			<td style="width:125px;"></td>
			<td style="width:165px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Post-operatively the patient remained symptom free. Routine gastroscopies at 4, 12 and 24&#160;months respectively showed that the cardio-esophageal junction remained at 38 cm from the dental arcade with no evidence of early recurrence or reflux esophagitis. There was mild gastritis of the antrum.
This technique has been performed in 32&#160;patients using&#160;absorbable biosynthetic mesh. Only one patient reported complication (Table 1).
<table border="1" fo:keep-togethe...

Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

This is a video showing laparoscopic mesh repair of a large, defined as greater than seven centimeters in length, sliding hiatus hernia using Gore Bio-A Mesh. This patient is a 68-year-old who presented with reflux symptoms, unresponsive to medical treatment and iron-deficiency anemia. Subsequent gastroscopy found Cameron lesions, large linear erosions in the gastric body and a 10 centimeter rolling hiatus hernia, compared to four centimeters in the previous gastroscopy a year ago.Prior to surgery, the patient was given Optifast for one week to reduce the liver size and assist the liver retraction intraoperatively. Establish pneumoperitoneum of 12 millimeters of mercury via a left subcostal Veress needle at Palmer's point. defined as three centimeters below the subcostal margin in the left midclavicular line.Using a direct bladeless optical access entry system, insert the port, which is supraumbilical, one hand span from the costal margin and to the left of the midline for the camera. Elevate the left lobe of the liver with a Nathanson liver retractor through a small left paraxiphoid incision. Place two further five millimeter ports under direct vision alongside the camera port.One at the level of the right midclavicular line. The second port on the left anterior auxiliary line. Insert a 10 millimeter port that is more cephalad at the left midclavicular line to create an ideal working triangulation.At this stage, most of the stomach will be herniating into the mediastinum. Therefore, pull the incarcerated stomach back into their abdominal cavity with continuous traction from the assistant to view the gastroesophageal junction. Enter the lesser curvature at the level of the pars flaccida of the gastrohepatic ligament and progressively dissect, reduce and excise the hernia sac using cauterization.This will lead to gradual exposure of both diaphragmatic crura. Note is made of the inferior vena cava and the caudate lobe of the liver in relation to the right crus. Mobilize the esophagus circumferentially by dividing all the congenital paraesophageal adhesions within the hiatus.Continue mobilizing the hiatus hernia off the bilateral crura to assist in retracting the hernia sac into the abdominal cavity. Identify and preserve the vagus nerves and both pleura. Create a window posteriorly between esophagus and thoracic aorta and place tape around the distal esophagus to allow gentle retraction.Mobilize the distal esophagus proximally, about 10 centimeters in distance, until there is adequate intraabdominal esophageal length, which is about three to four centimeters and so the esophagus lies free of tension. Approximate the diaphragmatic crura with three or four interrupted 1-O nonabsorbable braided sutures and reinforce the repair with a pre-shaped biosynthetic mesh that is introduced behind the esophagus in an onlay fashion. The right edge of the mesh should slide under the caudate lobe of the liver.If necessary, divide the left triangular ligament to accommodate the mesh. No pledgets are required if the quality and the tension of the crura is adequate. The extent of the crura closure should not cause narrowing or compression on the lower esophagus.A rough guide to adequate closure is being able to pass a grasper through the remaining gap. Secure the biosynthetic mesh with four mLs of fibrin glue. Perform a modified 180 degree anterior Dor fundoplication using 2-O nonabsorbable braided sutures by suturing the gastric fundus to the left crus, then sequentially fixing the folded greater curvature of the stomach anteriorly to the diaphragm and all the way to the proximal right crus.Four sutures are usually required. Incorporate the mesh into the first suture. Take care not to injure the pericardium during the fundoplication.A Bougie is not used. Insert a closed suction drain. Close skin with subcuticular 3-O synthetic absorbable and monofilament sutures.Postoperatively, the patient is nursed with the head elevated to 30 degrees to avoid aspiration. The patient was placed on regular antiemetics. The patient is allowed sips of water overnight followed by clear fluids if tolerated.The drain is usually removed after two days. The patient is advised to have a puree diet for four to six weeks.Results. 32 patients have undergone this technique.Of this, 26 were female and six were male. The median follow-up was 19 months. The median age for this group was 72 years of age.Of these 32 patients, four were type one, all of these were greater than seven centimeters, 23 would type three, of which three were recurrent, and lastly, four were type four. Of these patients, there was one recurrence and one mortality. This patient had a recurrent type three hiatus hernia, and this was a difficult dissection.Postoperatively, this patient was quite well and tolerated fluids well for the first 48 hours. She then unexpectedly rapidly decompensated from unrecognized cardiac tamponade.Conclusion. The key points for this procedure includes one, complete and circumferential mobilization of the hiatus hernia with excision of the sac.Two, adequate exposure and crura repair. Three, reinforcement of the cruroplasty with biosynthetic mesh. Four, further reinforcement of the repair with a modified 180 degree anterior Dor fundoplication.Using this technique, a low recurrence rate can be achieved. However, the patient should have ongoing followup with regular endoscopy. A healthier lifestyle is also encouraged.

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