Chabert Leopoldo Herrera, Fraind Jacob Joffe, Quintero Narcizo Leon
Department of Surgery, San Javier Hospital , Guadalajara, Jalisco, Mexico .
J Laparoendosc Adv Surg Tech A. 2015 Dec;25(12):1019-24. doi: 10.1089/lap.2015.0279. Epub 2015 Nov 19.
The purpose of this report is to describe a tension-free repair we have used successfully in 12 patients with large hiatal defects. It is based on the creation of a web-shoelace pattern of polypropylene (Prolene®; Ethicon, Somerville, NJ) suture of the crura that functions as a barrier, with the advantages of being stronger and more economical than a mesh without the potential complications that may follow mesh repair or suture repair of a large hiatus hernia without mesh. Despite a success rate of 85%-95% reported in large series with a mid- and long-term follow-up evaluation, significant complications have been associated with hiatus hernia repair. Some of these complications include a slipped Nissen repair with intrathoracic wrap migration and hiatal hernia recurrence, resulting from inadequate closure of the crura, fundoplication disruption, or dehiscence of the hiatoplasty.
From June 2013 to June 2014, we have used this technique on 12 patients (6 women and 6 men). Only patients with a large hiatus hernia of >4 cm were enrolled in this study. All patients underwent laparoscopic Nissen fundoplication and hiatoplasty using our technique. They were all severely symptomatic with dysphagia, retrosternal pain, gastroesophageal reflux disease, and respiratory symptoms at night.
Of the 12 patients who underwent this type of repair, all of them have reported good to excellent functional and symptomatic outcomes with minimal morbidity, no deaths, and no recurrence.
It is our belief that when a correct repair of the hiatus is not achieved with three stitches, adding more sutures will not lead to a tension-free repair, and this hiatoplasty will have an increased risk of dehiscence. It is for this reason that we recommend using our technique instead of using simple nonabsorbable sutures or a prosthetic mesh.
本报告旨在描述一种我们已成功应用于12例大裂孔缺损患者的无张力修补术。该方法基于创建一种聚丙烯（普理灵®；爱惜康公司，新泽西州萨默维尔）缝合线的网鞋带模式来缝合脚间肌，起到屏障作用，其优点是比补片更坚固、更经济，且不存在补片修补或无补片的大裂孔疝缝合修补可能伴随的潜在并发症。尽管在大型系列研究的中长期随访评估中报告成功率为85% - 95%，但裂孔疝修补仍存在显著并发症。其中一些并发症包括因脚间肌闭合不充分、胃底折叠术破裂或裂孔成形术裂开导致的尼森修补术滑脱伴胸腔内包裹移位以及裂孔疝复发。
2013年6月至2014年6月，我们对12例患者（6名女性和6名男性）采用了该技术。本研究仅纳入裂孔疝大于4厘米的患者。所有患者均采用我们的技术接受腹腔镜尼森胃底折叠术和裂孔成形术。他们均有严重症状，包括吞咽困难、胸骨后疼痛、胃食管反流病以及夜间呼吸症状。
接受此类修补术的12例患者均报告功能和症状改善良好至极佳，发病率极低，无死亡病例，且无复发。
我们认为，若三针无法实现裂孔的正确修补，增加缝线也不会实现无张力修补，且这种裂孔成形术裂开风险会增加。因此，我们建议采用我们的技术，而非简单的不可吸收缝线或人工补片。
