Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery.

BACKGROUND

One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary.

HYPOTHESIS

Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year.

DESIGN

Prospective nonrandomized trial of a consecutive sample.

SETTING

University-affiliated community hospital.

PATIENTS

Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration.

INTERVENTION

All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure.

MAIN OUTCOME MEASURES

Recurrences, complications, postoperative lower esophageal sphincter pressure, DeMeester score, esophagogastroduodenoscopy results, and barium swallow results.

RESULTS

All refundoplications were completed laparoscopically. There were no intraoperative complications. Twenty-one patients underwent laparoscopic Nissen fundoplication; in 3 patients, a laparoscopic Toupet fundoplication was performed. Previous antireflux procedures included an open Nissen fundoplication (n = 5), a laparoscopic Nissen fundoplication (n = 15), and a laparoscopic Toupet fundoplication (n = 4). Postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. During a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. The mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm Hg) and 1 year (11.9 mm Hg) after refundoplication. The mean DeMeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication.

CONCLUSION

Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.