The use of crural relaxing incisions with biologic mesh reinforcement during laparoscopic repair of complex hiatal hernias.

INTRODUCTION: Laparoscopic hiatal hernia repair has a better chance of success if the hiatus is closed without tension. This study attempts to answer the following questions: (1) What is the rate of hiatal hernia recurrence in patients who undergo hiatal closure with diaphragmatic relaxing incisions? (2) Can biologic mesh be safely substituted for synthetic mesh as coverage of the relaxing incisions?

METHODS: We identified all patients who underwent laparoscopic hiatal hernia repair at our institution between 2007 and 2013 and reviewed their clinical records. Radiologic recurrence was identified by an experienced radiologist and defined as the presence of any abdominal contents located above the diaphragm on esophagram. Clinical recurrence was defined as little or no improvement in symptoms, the development of a new symptom, or the need for medical, endoscopic, or surgical treatment of postoperative symptoms.

RESULTS: A minimum of 6 months of radiologic and clinical follow-up was available for 146 (40 %) patients, including 16 with relaxing incisions. There were 66 (45 %) recurrent hernias detected on esophagram. There was no difference in the rate of recurrent hiatal hernia among the three groups: Primary closure of the hiatus (21/36 [58 %]), primary closure with biologic mesh reinforcement (36/94 [38 %]), and relaxing incision with biologic mesh reinforcement (9/16 [56 %]; p = 0.428). Two reoperations were performed on patients who underwent left relaxing incisions and developed symptomatic diaphragmatic hernias through the left relaxing incisions. There were no complications associated with use of biologic mesh at the hiatus.

CONCLUSIONS: Rate of recurrent hiatal hernia is similar between patients who undergo diaphragmatic relaxing incisions and patients who undergo primary hiatal closure. Relaxing incisions can be safely performed on either crus; however, biologic mesh should not be used to patch a left-sided relaxing incision due to the risk of developing a diaphragmatic hernia.