Department of Surgery, Isala, Zwolle, The Netherlands.
Surg Endosc. 2024 May;38(5):2398-2404. doi: 10.1007/s00464-024-10703-3. Epub 2024 Apr 2.
Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement.
A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed.
54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%).
In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.
食管裂孔疝（HH）是膈的常见结构性缺陷。腹腔镜修复术通过缝合裂孔柱并进行胃底折叠术已成为标准治疗方法。为了降低 HH 的复发率，已使用网片加强，通常位于食管裂孔的后位。然而，后位网片加强的效果仍存在争议。对于需要进一步研究的复发机制，我们了解甚少。我们研究了 HH 复发的解剖位置，试图评估为什么尽管尝试了各种网片加强方法，但 HH 的复发率仍然很高。
对 2012 年至 2020 年间行食管裂孔疝修补术的患者前瞻性收集的数据进行回顾性病例系列研究。共有 54 例复发性食管裂孔疝手术患者纳入研究。由外科住院医师和高级外科医生对翻修手术的视频片段进行分析，以评估复发性 HH 的解剖位置。为了评估，将食管裂孔分为四个相等的象限。此外，收集并分析了患者的人口统计学、食管裂孔疝特征和手术细节。
纳入 54 例患者。初次修复与翻修手术之间的中位时间为 25 个月（IQR 13-95，范围 0-250）。43 例（80%）在前左象限、21 例（39%）在前右象限、21 例（39%）在后左象限和 10 例（19%）在后右象限存在疝复发。
在这项研究中，食管裂孔疝最常在前左象限复发，但后疝复发也不少见。根据我们的结果，我们假设前后裂孔强化都可能是降低食管裂孔疝复发率的合适方法。一项使用圆形可吸收网片的随机对照试验已启动，以验证我们的假设。
