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Joshua Gomez
Joshua Gomez

Hernia Surgery: Current Principles 1st Edition ... \/\/FREE\\\\



Warp knits and weft knits have been generated for use as implantable meshes to repair specific tissue sites and organs, such as those needed in hernia repair. Because of the looped stitches, the knitted structure is soft, flexible, and stretchable. It easily adapts to the movement of the human body [58], and has high elasticity, tensile strength, bursting strength and excellent porosity, which are key requirements for any implantable device that needs to mimic the biomechanical characteristics of the abdominal wall: tension of 16 N/cm with a 38% elasticity [38]. Given the interweaving, warp-knitted materials have a fixed structure that neither loosens nor peels off during cutting, regardless of the direction [55]. These material systems have been successfully commercialized and currently used worldwide. Table 4 lists some commercially available meshes classified according to the knitted technique, material, and type of filament.




Hernia Surgery: Current Principles 1st Edition ...



During the 24-month follow-up with no patients lost, no hernia recurrence wasidentified in any of the three groups, including the NFG, although our study has alimited casuistic the results were similar to those presented in studies publishedrecently, and in line with the current trend toward no mesh fixation in TAPP repairof both indirect primary hernias (regardless of size) and direct hernias measuringup to 3 cm. And it is worth underlining that the recurrence in non-fixation TAPP maybe due to clamshelling and dislocation of the mesh, while in TAPP with fixation(glue or tackers) prevent mesh folding. It may be a crucial factor preventingrecurrences; thus, sufficient dissection of preperitoneal space is of utmostattention.


Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.


Recurrent hiatal hernias are included in this review. Some authors advocate that any hernia seen on postoperative radiological contrast imaging or on gastroscopy is classified as a recurrence15,16. Other authors limit the definition of recurrence to those greater than 2cm in length17. Importantly, most reports indicate that small recurrences are seldom clinically significant18.


It is likely that some paraesophageal hiatal hernias develop from smaller hiatal hernias. Others may develop from anatomic changes such as occur with kyphosis and degenerative disc disease in the spine40. As more stomach moves up into the thorax, respiratory symptoms may predominate secondary to pulmonary compression and reduction in forced vital capacity10, 41. Recurrent aspiration pneumonia is also possible39. Later, with vascular compromise from volvulus, gastric mucosal ischemia may cause ulceration, bleeding and anemia. Iron deficiency anemia can be seen in up to 50% of patients with a paraesophageal hiatal hernia41.


There is little information available in the current literature about tailoring the fundoplication during hiatal hernia repair, though preoperative manometric data has been used to guide the degree of wrap8. The SAGES Guidelines for surgical treatment of gastroesophageal reflux disease20 found that a tailored approach to fundoplication is unwarranted in the surgical treatment of reflux, though this document did not examine the case of hiatal hernias.


The placement of a gastrostomy tube is often used to both provide fixation of the anterior stomach to the abdominal wall and to aid in post-operative venting of the stomach in cases of delayed gastric emptying. One of the first studies promoting an anterior gastropexy to reduce the recurrence rate after laparoscopic hiatal hernia repair described in a prospective series of 28 patients a repair with reduction of the hernia, sac excision, crural repair, anti-reflux procedure and routine anterior gastropexy156. No Type I hernias were included. No recurrences were reported in up to 2 years of follow-up evaluation. This finding has been supported by others; a recent study of 89 patients with large hiatal hernias undergoing laparoscopic repair concluded that the addition of a anterior gastropexy significantly reduced recurrent hernias103. Other reports concluded the opposite. Medium-term outcome in 116 patients having laparoscopic paraesophageal hernia repair157, with and without gastropexy, found no significant difference in recurrence rate.


Recurrent hiatal hernia repair is indicated when the symptoms match anatomical findings43. The revisional surgery can often be completed laparoscopically in experienced hands43, 89. Any previous fundoplication should be taken down in its entirety, the right and left crura exposed, and the hernia sac excised. Attention should be directed to ensuring adequate intra-abdominal esophageal length89. The success of laparoscopic revisional hiatal hernia surgery approaches that of the primary repair162, though there remains an increase in recurrence rates. Mesh can be safely used in revisional surgery163, though there is inadequate and underpowered data to support its use.


The majority of reports include an anti-reflux procedure in patients with preoperative gastroesophageal reflux171. In fact, 12 of 20 children developed recurrent reflux symptoms after a simple hiatal repair without an antireflux procedure in a historic cohort of one study170. Laparoscopic repair of even large paraesophageal hernias is feasible in the pediatric population173, 174. Most reports advocate resection166, 169, 171, 173, 175 or incision174 of the hernia sac. Laparoscopic Collis gastroplasty and Nissen fundoplication has been described for severe recurrent reflux in patients with esophageal atresia, gastroesophageal reflux, and recurrent hiatal hernia as young as 5 years of age151. In this series, one out of 6 patients had a gastric perforation that required open re-exploration. Hence this approach should be individualized to select patients where standard treatment has failed.


In the 100 years since Soresi performed the first operation to reduce a hiatal hernia and approximate the crura in 1919 via laparotomy, laparoscopic repair of giant hiatal hernia (GHH) has become the standard of care (1). Over this period, our understanding of GHH and the surgical techniques used to treat them has progressed. In 1956 Nissen described a fundoplication technique that we still use with minor modifications (2). One year later, Collis described the technique of transthoracic gastroplasty to treat short esophagus (3). Skinner showed the importance of the intraabdominal esophagus as part of the antireflux valve. This led to the current rationale for surgery of a tension-free reduction of the distal esophagus in patients with hiatal hernia. Skinner reported that the shortened esophagus is related to high recurrence rates of hiatal hernia after repair (4). Only recently, some twenty years ago, Maziak et al. published the first modern report of open transthoracic surgical GHH repair with routine Collis gastroplasty and fundoplication (5). That same year, Johnson et al. published a report of a completely laparoscopic hernia reduction with Collis gastroplasty and Nissen fundoplication (6). Over time and with strict adherence to the principles of tension-free hiatal hernia repair, laparoscopic repair of GHH became the standard of care. Several studies have shown shorter hospital stays and reduced perioperative complications, but similar long-term outcomes when compared to open techniques (7-10). Robotic-assisted GHH repair has also gained some popularity over the past 20 years (11-13), but is not in widespread use at this time and is conceptually the same as laparoscopic repair. Although open transabdominal and transthoracic approaches are still in use, surgeons at high-volume centers only use these approaches for a very small minority of patients when a minimally invasive approach is not feasible. We present the following article in accordance with the NARRATIVE REVIEW reporting checklist (available at -20-50).


Laparoscopic repair of GHH is the current standard of care. The basic tenets of the operation are reduction of hernia sac and herniated contents with extensive mediastinal dissection, obtain at least 2 cm of intra-abdominal esophagus after reduction, tension-free closure of the hiatus, and fundoplication based on individual patient characteristics. We also include gastric decompression and pleural drainage as important steps in laparoscopic repair of GHH.


The role of mesh in GHH repair is not justified based on the current literature. We do not think permanent mesh should ever be used since it can erode into the esophagus or stomach and lead to severe morbidity (21). There have been several papers in the literature endeavoring to compare mesh versus suture repair of the crura, but most do not have complete data and are retrospective. One clinical trial evaluated the use of biologic mesh in hiatal hernia repair versus no mesh in a prospective fashion, published in two papers (22,23). Although results at 6 months were encouraging, the follow-up at 5 years showed no difference in recurrence rates between both groups. On the occasions we encounter right crural tearing, we will make a relaxing incision in the right crus and patch it with Goretex mesh. The medial part of the mesh must not come in direct contact with the esophagus. The authors almost never use mesh, because there is no evidence to support its use and biologic mesh is costly. 041b061a72


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