This document summarizes several studies on surgical repair of hiatal hernias. It discusses the use of mesh reinforcement to reduce recurrence rates for both laparoscopic fundoplications and large paraesophageal hernia repairs. The studies found mesh reinforcement was associated with fewer recurrences compared to primary suture repair, with no reported instances of mesh erosion. Longer follow-up is still needed but current data support the use of mesh for hiatal repairs.

1. Hiatal Hernia

2. Surgical repair of recurrent hiatal hernia. Haider M , Iqbal A , Salinas V , Karu A , Mittal SK , Filipi CJ . Hernia. 2006 Jan 27;:1-7 The surgical management results of recurrent hiatal hernia repair are unknown in the laparoscopic era. The experience of the senior authors (CJF) and (SKM) is reported herein. From 1993 to 2004, 52 patients underwent re-operative hiatal hernia surgery at our center. Preoperative symptoms were heartburn, chest pain, dysphagia, regurgitation and pulmonary manifestations of gastroesophageal reflux disease. Patients had preoperative evaluation by upper endoscopy, pH-monitoring, esophagogram and manometry to assess the mechanism of failure. Pre- and postoperative symptoms were assessed utilizing a standardized questionnaire. Patients underwent laparoscopic repair (n=18), open laparotomy (n=6) and transthoracic surgery (n=28). Ninety-five percent follow-up was achieved with a mean follow-up of 34 months. Thirty-seven percent of patients encountered para-operative complications one of them died due to respiratory insufficiency. Five patients experienced a re-recurrent hernia. The symptom resolution was 65% for dysphagia, 68% for heartburn, 95% for chest pain and 79% for regurgitation. The overall patient satisfaction was 6.94 on a scale of 1-10. There was no significant difference in patient outcome when comparing the operative approaches or disease process. Surgical repair of recurrent hiatal hernias is safe and effective. Laparoscopic surgery is an appropriate alternative approach for recurrent hiatal hernia repair in selected patients.

3. Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications: a critical analysis of the available literature. Johnson JM , Carbonell AM , Carmody BJ , Jamal MK , Maher JW , Kellum JM , Demaria EJ . Surg Endosc. 2006 Jan 25 BACKGROUND: Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence. METHODS: A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both. RESULTS: Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract. CONCLUSIONS: The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.

4. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Muller- Stich BP , Holzinger F , Kapp T , Klaiber C . Surg Endosc. 2006 Jan 21; Department of Surgery, Kantonsspital St. Gallen, St. Gallen, 9007, Switzerland. BACKGROUND: The recurrence rate after laparoscopic repair of hiatal hernias with paraesophageal involvement (LRHP) is reported to be high. Mesh reinforcement has been proposed with the objective of solving this problem. This study aimed to compare the outcome of LRHP before and after the introduction of mesh reinforcement. METHODS: Between 1992 and 2003, 56 consecutive patients received LRHP including posterior crurorrhaphy and additional fundoplication. Of these 56 patients, 17 underwent a mesh-reinforced hiatoplasty. Perioperative outcome was assessed retrospectively, and follow-up assessment was performed according to protocol including a barium contrast swallow. RESULTS: The follow-up period averaged 52 +/- 31 months (range, 9-117 months). The recurrence rate for hiatal hernia without mesh reinforcement was 19% (7/36). No recurrence (0/16) was observed in patients with mesh reinforcement. The intraoperative complication rate was 9%, and the perioperative morbidity rate was 14%. There were neither mesh-related complications nor operation-related deaths. CONCLUSIONS: Although challenging, LRPH is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement.

5. Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery. Granderath FA , Carlson MA , Champion JK , Szold A , Basso N , Pointner R , Frantzides CT Department of General, Visceral and Transplant Surgery, University Hospital of Tuebingen, Tuebingen, Germany. Surg Endosc. 2006 Jan 19; BACKGROUND: Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus. METHODS: A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected. RESULTS: The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure. CONCLUSIONS: Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.

6. Laparoscopic mesh repair antireflux surgery for treatment of large hiatal hernia. Zilberstein B , Eshkenazy R , Pajecki D , Granja C , Brito AC . Gastromed - Zilberstein institute, Sao Paulo - SP - Brazil. [email_address] Dis Esophagus. 2005;18(3):166-9. SUMMARY: One of the most frequently occurring anatomic failures after laparoscopic fundoplication is migration of the wrap into the chest, with or without disruption. This so-called 'slipped' Nissen fundoplication may be the result of inadequate closure of the diaphragmatic crura or rupture of the sutures or disruption of the muscle fibers approached. From January 2000 to December 2002, a total of seven patients (four male) with a mean age of 56 years (range 22-72 years), were considered for laparoscopic antireflux procedure using DACRON mash to reinforce the crural hiatal closure. The patients were operated under general anesthesia; laparoscopy was performed by classical approach with five trocars. The mean operative time was 120 minutes (range 40-240 min). There were no deaths. The average of postoperative hospital stay was 3.5 days (range, 3-5). Patients returned to normal activities usually on postoperative day 10 (range, 7-15). The follow-up time was at least 2 years. There was only one late complication related to the use of DACRON mesh at the hiatus, due to migration of the mesh into the esophageal lumen causing disphagia. In conclusion the mesh repair antireflux surgery is a good alternative for closing the diaphragmatic defect in large hiatal hernias or to correct this problem in case of recurrence or Barrett's esophagus.

7. Magy Seb. 2005 Apr;58(2):100-5. [Our experiences during laparoscopic giant paraesophageal hernia repair (1993-2004)] Hajdu Z , Bodnar Z , Toth D . Hajdu-Bihar Megyei Onkormanyzat Kenezy Gyula Korhaz-Rendelointezet, a Debreceni Egyetem Orvos- es Egeszsegtudomanyi Centrum Oktato Korhaza, Altalanos Sebeszeti Osztaly, Debrecen. INTRODUCTION: Following both open and laparoscopic surgery for large hiatus hernias the recurrence rate is high. During the last decade we found that the correct indication and operation technique at primary operation should be prophylactic against recurrent hiatus hernia and postoperative dysphagia. MATERIAL AND METHOD: Between 1993 and 2004 more than 350 antireflux procedures were performed in our department. In 35 patients direct crural reconstructions and onlay-mesh implantation was necessary because of extremely large hiatus hernias. The onlay-mesh implantation and tension-free hiatus reconstruction beside correct calibration of the lower esophageal sphincter (LES) decreases the chance of recurrence and postoperative dysphagia. RESULTS: In the early period there were five recurrent hernias due to crural reconstruction with absorbable sutures, weak intracorporally knotted crural sutures and extremely large hiatus hernia. During laparoscopic reoperations reconstructions with onlay mesh implantation were performed successfully. CONCLUSION: The mesh implantation with correct indication and intraoperatively calibrated wrap decrease recurrence and postoperative dysphagia. Laparoscopic reoperation is a safe procedure with good results in trained hands.

8. J Laparoendosc Adv Surg Tech A. 2005 Jun;15(3):279-84. Laparoscopic tension-free repair of large paraesophageal hiatal hernias with a composite A-shaped mesh: two-year follow-up. Casaccia M , Torelli P , Panaro F , Cavaliere D , Saltalamacchia L , Troilo BM , Savelli A , Valente U . Advanced Laparoscopic Unit, Department of General Surgery and Transplantation, St. Martino Hospital, University of Genoa, Genoa, Italy. Marco.Casaccia@unige.it BACKGROUND: Surgical repair of large hiatal hernias is associated with a high recurrence rate when the repair is made by simple cruroplasty. The use of a mesh goes from a reinforcement of a simple cruroplasty to a tension-free repair. We discuss the evolution of this approach and evaluate the outcomes of 27 patients with type II (n = 9), type III (n = 16), and type IV (n = 2) hiatal hernias treated laparoscopically. METHODS: Between November 1999 and October 2003, 27 patients (18 women and 9 men) received laparoscopic repair of large hiatal hernias by means of an A-shaped polypropylene-polytetrafluoroethylene mesh. A total or a partial fundoplication was associated in all cases. The mean age was 60.1 years (range, 36-76 years). The patients presented with symptoms of 2 months to 10 years in duration. Preoperative assessment included an upper gastrointestinal endoscopy, esophageal manometry, 24 hour pH monitoring, and barium swallow. Concomitant esophagitis was found in 16 patients and impaired esophageal peristalsis in 2 patients. Four patients had concomitant gallbladder disease treated at the same time. RESULTS: No conversions occurred in our series. There was no perioperative mortality, and morbidity was low. Follow-up averaged 27 months (range, 6-46 months). There has been 1 recurrence (3.7%), prolonged dysphagia in 4 cases, and no mesh erosion. CONCLUSION: Early results confirm the feasibility of the tension-free repair of large hiatal hernias and the effectiveness of the composite A-shaped mesh. Long-term follow-up for all patients is necessary to determine the real incidence of recurrence.

9. Zhonghua Yi Xue Za Zhi. 2005 Mar 9;85(9):584-5. [Laparoscopic treatment of esophageal hiatal hernia: analysis of 11 cases] Cai XJ , Zheng XY , Yu H , Huang DY , Liang X , Yang J , Li W , Wang YF . Laparoscopic Surgery Center, Department of General Surgery, Sir Run Run Shaw Hospital of Zhejiang University, Hangzhou 310016, China. OBJECTIVE: To investigate the effect and safety of laparoscopic treatment in patients with esophageal hiatal hernia. METHODS: Eleven patients with esophageal hiatal hernia, 9 males and 2 females, with the mean age of 56, accepted laparoscopic treatment. Two cases were treated by hernia repair merely and 9 cases were treated by hernia repair and fundoplication (Nissen's operation) one of which accepted laparoscopic cholecystoectomy at the same time. RESULTS: All patients were treated successfully. The operation time was 2.5 hours (1.5 - 5 hours) and the blood loss was between 20 - 200 ml. The patients began to accept liquid diet 24 - 36 hours after operation. There was no postoperative complication and all the clinic symptoms disappeared. The mean hospitalization time was 8 days (6 - 15d). CONCLUSION: Laparoscopic treatment of esophageal hiatal hernia provides a safe and minimal invasive procedure.

10. Surg Clin North Am. 2005 Jun;85(3):411-32. Management of paraesophageal hernias. Landreneau RJ , Del Pino M , Santos R . Division of Thoracic and Foregut Surgery, University of Pittsburgh Medical Center, Shadyside Medical Center, 5200 Centre Avenue, Pittsburgh, PA 15232, USA. landreneaurj@upmc.edu A tailored approach to the management of patients who have para-esophageal herniation appears to be the best policy. No one approach can universally apply to this patient population if optimal therapy, quality of life, and overall survival are to be optimized.

11. Br J Surg. 2005 May;92(5):648-53. Laparoscopic repair of large hiatal hernias. Aly A , Munt J , Jamieson GG , Ludemann R , Devitt PG , Watson DI . Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia. ahmad_aly@bigpond.com <ahmad_aly@bigpond.com> BACKGROUND: The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long-term outcome of laparoscopic repair of large hiatal hernias. METHODS: All patients who had undergone laparoscopic repair of a large hiatus hernia (more than 50 per cent of the stomach in the hernia) with a minimum 2-year clinical follow-up were identified from a prospectively maintained database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. Multivariate analysis was used to identify factors associated with recurrence. RESULTS: Of 100 eligible patients, clinical follow-up was available in 96. Follow-up ranged from 2 to 8 (median 4) years. In patients with preoperative reflux symptoms, there were significant improvements in heartburn and dysphagia scores after surgery. Overall, 80 per cent of patients rated their outcome as good or excellent. Sixty patients underwent a postoperative barium meal examination that identified 14 radiological hernia recurrences (eight small, three medium and three large). Four other patients in this group of 60 had previously undergone reoperation for early and late recurrence (two of each), giving an overall recurrence rate of 18 of 60 (30 per cent). One third of patients with recurrence were totally asymptomatic and the presence of postoperative symptoms did not reliably predict the presence of anatomical recurrence. Younger age and increased weight at operation were independent risk factors contributing to recurrence. CONCLUSIONS: Laparoscopic repair of large hiatal hernias yields good clinical outcome. Recurrence after laparoscopic repair seems to be more common than previously thought. Objective anatomical studies are required to determine the true recurrence rate. The majority of recurrences are not large and do not cause significant symptoms. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

12. Tension-free repair of hiatal hernia during laparoscopic fundoplication: a ten-year experience. Gryska PV , Vernon JK . Department of Surgery, Newton-Wellesley Hospital, Newton, MA 02462, USA. [email_address] Hernia. 2005 May;9(2):150-5. Epub 2005 Feb 19. BACKGROUND: The breakdown of a hiatal hernia repair can lead to clinical failure. The use of prosthetic material at the esophageal hiatus to strengthen the crural repair is relatively new and questions remain. This report examines the safety and efficacy of a tension-free crural repair with mesh. PATIENTS AND METHODS: Since 1993, 135 consecutive patients (19-86) [9 re-do] completed laparoscopic tension-free hiatal hernia repair prior to Nissen wrap. Esophageal hiatus was patched with a PTFE mesh (first 112 patients) or a PTFE/ePTFE composite (23 patients) secured across the defect with staples to each crura. 130 patients completed a phone questionnaire during 2003/2004 (mean f/u 64 months). RESULTS: There have been no short-term nor long-term infections related to the PTFE mesh. Symptoms were resolved or improved and resolved with meds in 122/130 (94%). Early re-herniation occurred in one patient after vigorous exercise. CONCLUSIONS: Mesh repair/patch of the esophageal hiatus can be done without infection, with results similar to standard crural repair and consistent with surgical principles of non-tension.

13. Ann Surg. 2005 Jan;241(1):185-93 The history of hiatal hernia surgery: from Bowditch to laparoscopy. Stylopoulos N , Rattner DW . Massachusetts General Hospital, Boston, Massachusetts 02114, USA. OBJECTIVE: This review addresses the historical evolution of hiatal hernia (HH) repair and reports in a chronological fashion the major milestones in HH surgery before the laparoscopic era. METHODS: The medical literature and the collections of the History of Medicine Division of the National Library of Medicine were searched. Secondary references from all sources were studied. The senior author's experience and personal communications are also reported. RESULTS: The first report of HH was published in 1853 by Bowditch. Rokitansky in 1855 demonstrated that esophagitis was due to gastroesophageal reflux, and Hirsch in 1900 diagnosed an HH using x-rays. Eppinger diagnosed an HH in a live patient, and Friedenwald and Feldman related the symptoms to the presence of an HH. In 1926, Akerlund proposed the term hiatus hernia and classified HH into the 3 types that we use today. The first elective surgical repair was reported in 1919 by Soresi. The physiologic link between HH and gastroesophageal reflux was made at the second half of the 20 century by Allison and Barrett. In the midst of a physiologic revolution, Nissen and Belsey developed their famous operations. In 1957, Collis published his innovative operation. Thal described his technique in 1965, and in 1967, Hill published his procedure. Many modifications of these procedures were published by Pearson and Henderson, Orringer and Sloan, Rossetti, Dor, and Toupet. Donahue and Demeester significantly improved Nissen's operation, and they were the first to truly understand its physiologic mechanism. CONCLUSION: Hiatal hernia surgery has evolved from anatomic repair to physiological restoration.

14. Surg Clin North Am. 2005 Feb;85(1):105-18, Laparoscopic repair of paraesophageal hernia. Lal DR , Pellegrini CA , Oelschlager BK . Department of Surgery, Center for Videoendoscopic Surgery, University of Washington Medical Center, 959 NE Pacific Street, Box 356410, Seattle, WA 98195, USA. Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.

15. Arch Surg. 2004 Dec;139(12):1286-96; discussion 1296. Mesh in the hiatus: a controversial issue. Targarona EM , Bendahan G , Balague C , Garriga J , Trias M . Service of Surgery, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain. atargarona@hsp.santpau.es OBJECTIVE: To analyze the experience acquired to date on the use of prosthetic mesh to prevent recurrence after laparoscopic repair of paraesophageal hernia. DATA SOURCES: Current English-language literature review. STUDY SELECTION: Case reports, series, and opinion articles on the use of mesh for paraesophageal hernia repair. DATA EXTRACTION AND SYNTHESIS: Study type and results were analyzed. Most articles were short case series. Few comparative or randomized trials assessing the procedure have been published to date. The information available showed that the use of a mesh for hiatal repair was safe and prevented recurrence. However, data on the long-term results were lacking, and infrequent but severe complications may arise. CONCLUSIONS: The mesh should be used selectively, and the decision to proceed should be based on clinical experience. In light of the evidence available, however, it appears to be safe, and the fears expressed in the past have not been confirmed.

16. Semin Laparosc Surg. 2004 Sep;11(3):161-9. The massive hiatal hernia: dealing with the defect. Targarona EM , Balague C , Martinez C , Garriga J , Trias M . Service of Surgery, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain. etargarona@hsp.santpau.es. The success of laparoscopic fundoplication has extended the use of the laparoscopic approach to treating more difficult situations such as paraesophageal hernias (PEHs) or type III (mixed) hiatal hernia. The results have shown that laparoscopic repair is feasible and safe. However, several series have shown recurrence rates of up to 42% as a result of difficulty in the closure of the hiatal gap. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure. This review analyses the different techniques proposed to prevent recurrence after laparoscopic repair of PEHs. The information currently available shows that the use of a mesh for hiatal repair is safe and prevents recurrence. However, data on the long-term results are lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience.

17. Hernia. 2004 Dec;8(4):311-7. Hiatal hernia recurrence: 2004. Puri V , Kakarlapudi GV , Awad ZT , Filipi CJ . Department of Surgery, Creighton University, Suite 3700 601 N. 30th St, Omaha, NE 68131, USA. BACKGROUND: The incidence of laparoscopic hiatal hernia recurrence is less than ideal. The reasons are more theoretical than objective, as the literature has little data in support of specific mechanisms of recurrence. METHOD: A recent literature review using all Internet-available, English-language articles on laparoscopic hernia repair was completed. RESULTS: A multitude of mechanisms of recurrence are suggested, but only surgeon inexperience, postoperative vomiting, heavy lifting, and retention of the hernia sac are supported by data. CONCLUSION: The incidence of hiatal hernia recurrence has stabilized. The role of an onlay mesh prosthesis for the prevention of hiatal hernia recurrence is under investigation, and long-term results are awaited.

18. J Chir (Paris). 2004 May;141(3):157-64. [Late complication of hiatal hernia surgery] [Article in French] Suc B . Service de Chirurgie Generale et Digestive Hopital de Rangueil - Toulouse. suc.b@chu-toulouse.fr

19. Surg Endosc. 2004 Jul;18(7):1051-3. Epub 2004 May 27. Prevention of recurrence by reinforcement of hiatal closure using ligamentum teres in laparoscopic repair of large hiatal hernias. Varga G , Cseke L , Kalmar K , Horvath OP . Department of Surgery, Medical Faculty, University of Pecs, H-7643 Pecs Ifjusag u.13, Hungary. gvarga@iseb.pote.hu BACKGROUND. Several attempts were made to develop an effective technique to reduce the high recurrence rate associated with the repair of large hiatal hernias. METHODS: A new laparoscopic technique was introduced to reinforce hiatal closure with the ligamentum teres. Its feasibility, safety, and efficacy were evaluated. Four patients with gastroesophageal reflux disease and large hiatal hernia (>6 cm) entered the study. After closure of the diaphragmatic crura the teres ligament was dissected, brought behind the esophagus, and sutured to the crura. A fundoplication was also added. Patients were followed with barium swallow at 3 months postoperatively. RESULTS: The mean operation time was 109.5 min. No intraoperative complications, perioperative morbidity, or mortality were registered. At the follow-up, barium swallows revealed no recurrence. CONCLUSION: On the basis of these preliminary results laparoscopic reinforcement of the hiatal closure with the ligamentum teres seems feasible and safe; therefore this promising technique should be considered as an option for the treatment of large hiatal hernias.

20. Surg Endosc. 2004 Jul;18(7):1045-50. Epub 2004 Jun 10. Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia. Targarona EM , Novell J , Vela S , Cerdan G , Bendahan G , Torrubia S , Kobus C , Rebasa P , Balague C , Garriga J , Trias M . Department of Surgery, Hospital de Sant Pau, Padre Claret 167, 08025, Barcelona, Spain. etargarona@hsp.santpau.es BACKGROUND: Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of < or =40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patient's quality of life. METHODS: All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients' clinical files. In March 2003, all patients with > or =6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients' quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI]. RESULT: During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28-93). Thirty seven of them had a follow-up of > or =6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients' postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group. CONCLUSION: The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.

21. Dig Dis Sci. 2004 Feb;49(2):243-7. Related Articles, Links Relationship between hiatal hernia and inguinal hernia. De Luca L , Di Giorgio P , Signoriello G , Sorrentino E , Rivellini G , D' Amore E , De Luca B , Murray JA . Department of Gastroenterology, Pellegrini Hospital, ASL NA1, Napoli, Italy. leonardodeluca@hotmail.com Several theories explain the development of hiatal hernia (HH). Since inguinal hernia (IH) is due to abdominal wall herniation, we hypothesized that if HH is caused by an excessive &quot;push&quot; from increased intraabdominal pressure, there would be a greater than chance association between HH and IH. The aim of this prospective case-control study was to determine the relationship between HH, identified at endoscopy, and IH, found on clinical examination. Outpatients, who were referred for elective upper GI endoscopy at the Endoscopic Unit, from January 1999 to December 1999, were evaluated. Data were collected regarding gender, age, BMI, presence or absence of HH, length of HH, and presence of IH on detailed abdominal examination of each subject. Five hundred fifty-nine outpatients were enrolled in this study. Of these, 128 (23%) had HH, whereas 431 (77%) patients did not. The average length of the HH was 2.7 +/- 0.9 cm (range, 1.5-6 cm). The overall risk of IH in patients with HH is 2.5-fold compared to those without HH (OR = 2.59). Obesity (BM, >25) was an additional risk factor for IH in patients with HH compared with normal weight (BMI, 21-25) (P < 0.05). Males with HH were more likely to have IH than females (OR = 2.86; 95% CI = 1.35-6.08). Inguinal and hiatal hernias occur together more often than expected by chance alone. Male gender and obesity increase the risk of association. These results suggest that a common etiology may exist for both IH and HH, at least in some patients, and support the hypothesis that &quot;push&quot; factors may contribute to the etiology of HH.

22. Chirurgia (Bucur). 2003 May-Jun;98(3):209-18. Related Articles, Links [Laparoscopic approach in large hiatal hernia--particular considerations] [Article in Romanian] Munteanu R , Copaescu C , Iosifescu R , Timisescu L , Dragomirescu C . Clinica de Chirurgie Generala, Spitalul Clinic, Sf. Ioan, Bucuresti. rubinmunteanu@hotmail.com Large hiatal hernia are associated with permanent or intermittent protrusion of more than 1/3 of the stomach into the chest, single or in associated with other organs, a hiatal defect greater than 5 cm and various complications related to the morphological and physiological modifications. While the laparoscopic approach in small hiatal hernia and gastro-esophageal reflux disease is a standard procedure in large hiatal hernia persists a number of questions and controversies. Between 1995 and 2002 a number of 23 patients with large hiatal hernia (9 men, 14 women), mean age 65.8 years (range 49 to 77) underwent laparoscopic surgery. The majority of the patients had complications of the disease (dysphagia, severe esophagitis, anemia, respiratory and cardiac failure). In 16 cases was a sliding hernia (one recurrent after open procedure), in 2 paraesophageal and in 5 a mixed hernia (two &quot;upside-down&quot; type). In 7 cases we perform, in the same operation, cholecystectomy for gallbladder stones and in one cases Heller myotomy for achalasia. In all cases the repairs was performed by using interrupted stitches to approximate the crurae, but in three of them (recurrent and upside down hernia) we consider necessary to repair with a polypropylene mesh (10 x 5 cm) with a &quot;keyhole&quot; for the esophagus. In these particular cases we do not perform a antireflux procedure, in others 20 cases a short floppy Nissen was done. During the operation one patient developed a left pneumothorax and required pleural drainage. Postoperatively one patient had dysphagia treated by pneumatic dilatation and another die 3 weeks after the surgery because severe respiratory and cardiac failure. CONCLUSIONS: Laparoscopic approach is a feasible and effective procedure with good postoperatively results, but required good skills in mininvasive technique.