Primary repair of giant hiatus hernia is satisfactory without mesh: early results of a method revisited

Abstract

Small numbers of hiatus hernias are very large, cause other nonreflux symptoms as well, and have an attached morbidity and mortality through strangulation. Patients are elderly and unfit, and surgery has been troubled by recurrence. Mesh repair has been advocated in an attempt to reduce a perceived high revision rate. We describe the early results of a "composite" form of laparoscopic repair where no mesh has been used, with excellent early results in levels of symptom control, morbidity, mortality, and recurrence, and discuss the value of mesh repair as a primary operation against the recently recognized severe complications secondary to mesh repair failure. The technique requires five-port laparoscopy, primary nonabsorbable diaphragmatic repair, and fixation of the cardioesophageal junction, within a fundoplication, to the posterior crural repair and median arcuate ligament. Thirty-eight patients with a mean age of 70 years operated on during 1 year had a recurrence of 6% but of minimal size by objective measure between 4 and 19 months of operation. Mesh repair in the literature is poorly supported, highly complicated, and by these figures not required.