Introduction

According to current literature, giant hernias (more than 1/3 of stomach migrated with or without other organs) is a rare condition, representing 5–10% of all hiatal hernias [1–3]. They can be completely asymptomatic, or responsible for a variety of clinical signs and symptoms, e.g., obstructive symptoms, such as vomiting and dysphagia, due to the mechanical effects on the herniated stomach; respiratory symptoms such as cough or dyspnea related to chronic aspiration or lung compression; anemia, due to chronic or acute bleeding; and GERD-related symptoms such as heartburn or regurgitation. As no satisfactory medical options are available for the treatment of giant hernias, surgical therapy is recommended for symptom relief. The most important threat from this kind of hernia, even if asymptomatic, is the risk of rare but severe complications such as perforation, bleeding and gastric strangulation. With the improved safety and efficacy of laparoscopic fundoplication techniques, most authors routinely recommend elective laparoscopic repair on diagnosis, even for asymptomatic or minimally symptomatic hernias, to prevent the risk of life-threatening complications and avoid any need for emergency surgery.

Though various studies have shown that laparoscopic hernia repair is safe and effective [4, 5], and that it carries a lower morbidity rate than the open approach, a high recurrence rate of up to 42% has been still described [5–7], making many authors suggest the use of a prosthesis mesh to reduce the recurrence rate. Due to concern about the risk of severe complications (i.e., migration, erosion and stenosis) reported by some authors, we prefer to avoid mesh hiatoplasty. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent a laparoscopic repair with direct closure of the hiatus without using any meshes.

Materials and methods

From January 2000 to March 2010, 55 patients with type III and IV hiatal hernias were treated at the Tuscany Regional Referral Centre for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium swallow X-ray and follow-up by physical examinations and symptom questionnaires.

Seventeen patients were excluded from the study, i.e., 15 operated via a thoracic open approach (Collis-Nissen operation), and 2 operated by laparotomy. This analysis was conducted on the outcome of the remaining 38 patients treated laparoscopically. Their mean follow-up was 49 months (12–88 months). The preoperative workup included accurate physical examination and clinical history, esophagoscopy and barium X-ray in all patients, esophageal manometry in 25 (65.8%) and 24-h pH monitoring in 20 patients (52.6%). All the procedures were carried out electively.

A total of 22 patients (57.9%) underwent a laparoscopic Nissen and 16 (42.1%) laparoscopic Toupet procedure, as described below. To reduce the risk of recurrence, 30/38 (78.9%) patients had a gastropexy too. A standardized symptom questionnaire was administered pre-operatively and repeated at the follow-up. Patients individually scored symptoms based on severity: 0 (no symptoms); 1 (mild); 2 (moderate); 3 (severe).

The symptoms considered were: pain, pyrosis, belching, regurgitation, dysphagia, nausea and vomiting, postprandial abdominal distension and dyspnea.

A barium X-ray was performed in all the patients after 1 month and 1 year, and repeated during further follow-up.

Surgical technique

Patients are placed supine on the split-leg operating table with their arms by their sides. The primary surgeon stands between the patient’s legs. Pneumoperitoneum is induced using a 10-mm trocar inserted, in open or semi-open fashion, just above the umbilicus in the midline position. After placing the laparoscopic camera, four other trocars are inserted under direct vision: a 10-mm trocar in the right upper quadrant to insert an expandable liver retractor, a 10-mm trocar in the left upper quadrant and a 5-mm trocar in the right upper quadrant for the surgeon’s right and left hands, respectively, and a 5-mm trocar laterally, in the left lower quadrant, which is used by the second assistant to retract the stomach. A 30° laparoscope camera is held by the first assistant on the patient’s right.

The first step involves the reduction of the hernia in the abdomen. The lesser omentum is opened with the ultrasonic dissector and the right crus is exposed. A good traction on the gastric wall is needed to pull down the hernia properly. The peritoneum is incised over the right and the left crus, and the whole peritoneal sac is carefully excised to reduce the risk of recurrence. Then the crura are fully exposed. A silicon tube is passed through a retroesophageal window for gastroesophageal junction retraction, lifting the posterior vagal nerve. The distal esophagus is dissected high in the mediastinum to obtain a floppy reduction in abdomen of the gastroesophageal junction. A direct hiatoplasty is then performed over a 48 Fr. bougie, suturing the right and the left crus, behind the esophagus, usually with two or three interrupted non-absorbable sutures.

The gastric fundus is then mobilized by dissecting one or two short gastric vessels and wrapped around the esophagus, completing a Nissen or a Toupet antireflux procedure based on the manometric results. A gastropexy is generally performed at the end of the procedure, fixing the anterior wall of the stomach, next to the great curvature, to the anterior abdominal wall with stitches or by gastrostomy. The suture is done with the aid of a straight needle passed through the stomach and it is tied extracorporeally after the pneumoperitoneum has been released. For the gastrostomy, two purse strings are fashioned around a Foley catheter inserted in the stomach and brought to the outside of the abdomen. Finally, a nasogastric tube is inserted (except for patients who have had a gastrostomy) and removed on the first postoperative day. A soft drainage catheter is then passed through the hiatus into the mediastinum and kept in place for the first two postoperative days to check for any hemorrhage. A barium X-ray is performed in all patients on the first postoperative day. Patients are allowed a liquid diet on the first day after surgery and a soft diet on the second.

Results

There were 12 males (31.6%) and 26 females (68.4%), with a median age of 62 years (range 36–83). They were operated for 26 type III (68.4%) and 12 type IV (31.6%) hernias. None of the patients had previously undergone surgery for gastroesophageal reflux disease or hiatal hernia. One had a history of laparotomy for peritonitis of unknown cause; esophagoscopy identified hiatal hernia in all cases, esophagitis in 18 (47.4%), gastritis in 8 (21%) and Barrett’s esophagus in 4 (10.5%).

The preoperative and postoperative symptoms are reported in Table 1.

Table 1 Preoperative and postoperative symptoms
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There were no conversions to laparotomy and the mortality rate was null. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 (42.1%). One patient had intraoperative complications (2.6%), i.e., perforation of the gastric fundus during its dissection, which was repaired with a stapler. Postoperative complications occurred in three patients (7.9%): one had a postoperative hemoperitoneum treated using a new laparoscopic procedure; one had a postoperative pulmonary embolism, successfully treated with medical therapy; and one had an early recurrence, on the first postoperative day due to a severe vomiting episode, and required immediate laparoscopic reoperation (this patient has remained asymptomatic and recurrence free after 40 months).

The mean follow-up period for these 38 patients was 49 months (range 12–88 months).

Barium swallow was performed in all patients after the first postoperative day, 1 month after the first year and at the last follow-up (from 12 to 88 months, mean 49 months).

A radiological recurrence was found in five patients (13.1%); four of them had a Nissen, and one a Toupet procedure. Only one out of these five had no gastropexy. Three of these patients (7.9%) were asymptomatic and received no further treatment. Two (5.2%) were reoperated on: one had a recurrent paraesophageal hernia recurrence after 1 month and underwent a new laparoscopic hernia repair; the other had a Nissen fundoplication slippage after 27 months and underwent a laparoscopic Toupet procedure (Table 2). All 38 patients improved, with a significant reduction in the frequency and severity of their preoperative symptoms. After surgery, none of the patients complained of grade 3 symptoms, and they reported a clear improvement in pain, heartburn, regurgitation and nausea (Table 1). Of the 38 patients, 35 (92%) were satisfied with the outcome of the procedure.

Table 2 Results of 38 consecutive laparoscopic giant hiatal hernia repair
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Discussion

The most important risk, even for asymptomatic or minimally symptomatic large hernias, is the sudden onset of life-threatening complications, such as perforation, bleeding and gastric strangulation, but the risk is low and has probably been overestimated in the past. According to some authors [8], the mortality and morbidity related to serious complications have reasonably decreased in recent years, so they argue against elective treatment of asymptomatic or minimally symptomatic hernias and recommend surgery only in case of symptom progression or when complications occur. Stylopoulos et al. [8] recently compared the possible clinical outcomes of laparoscopic repair versus watchful waiting in a hypothetical cohort of patients with asymptomatic or minimally symptomatic hernia, based on variables estimated from the literature and large administrative databases. They found the mortality rate for emergency surgery lower than the figure reported in other studies (i.e., 5.4% instead of 17%), and that the annual likelihood of patients managed with a watchful waiting strategy needing emergency surgery was 1.1%. The watchful waiting strategy proved the best option for 83% of patients and the annual probability of their symptoms progressing was 13.8%. We agree with the above attitude and we only recommend surgery for symptomatic patients, taking a watchful waiting approach to asymptomatic or minimally symptomatic cases. All the patients in our series were symptomatic at the baseline and reported a significant improvement in their symptoms after surgery.

One of the most crucial technical points in surgery for large hernias concerns the repair of the hiatus. The high recurrence rate, up to 42% [4, 6, 7, 9, 10] after laparoscopic repair of large hernias, is considered to be the most disappointing aspect of this kind of treatment. Because the hiatal defect is so large in patients with giant hernias, the right and left crura are very thin and it can make a direct closure challenging because of the tension needed to juxtapose the crura. Studies on large series have shown that crural closure failure is the most frequent problem requiring revision surgery after hiatal hernia repair [11, 12].

Assuming that intrathoracic wrap migration is due to inadequate hiatal closure or postoperative crural disruption, given that the diaphragm is under stress during breathing and straining, many authors [11, 13–15] encourage the use of prosthetic mesh for reinforcement when repairing large hiatal hernias. Although they have reported a significant reduction in recurrence rate, only few prospective randomized studies have been published to date and different surgical techniques (interposition, crural onlay, anterior repair, etc.) and prosthetic material (polypropylene, PTFE, biological mesh, etc.) were used. The results reported in a recent series of hiatal hernia repair with or without mesh are shown in Table 3 [9, 10, 13, 16–33]. In most of the series, only symptomatic patients are examined to identify any recurrences, so it is difficult to identify the rate of anatomically and radiologically evident recurrences, and the figure is probably underestimated in both groups. In addiction some reports have described cases of mesh erosion or migration, or the development of severe adhesions or fibrotic strictures causing distal esophagus stenosis [34]. A recent study [35] collected 28 cases of mesh-related complications (17 intraluminal mesh erosions, 6 esophageal stenoses, and 5 dense fibroses). Six patients required esophagectomy, two had partial gastrectomy, one had total gastrectomy, one had a stent to deal with the dysphagia, one had the mesh removed endoscopically, and 13 had it removal surgically; four patients required no surgery. Although the use of prosthetic reinforcement to treat fascial defects elsewhere in the body is safe and carries no life-threatening complications, their use in hiatal hernia repair remains a controversial issue. In fact, while the intense scarring due to the presence of the prosthesis is useful in inguinal and ventral hernias (and this is the rationale behind its use), at other sites, and in the hiatal region in particular, it can cause problems. The complications do not depend on the type of material, the shape of prosthesis or the placement method used, and problems can develop even many years after the surgical procedure [35]. Although reports of mesh repair complications are limited and anecdotal, the numbers involved are most probably underestimated, and the morbidity and mortality associated with esophagectomy are serious. Given the risk of having to perform major surgery in the event of complications, there is no justification for routine mesh placement in the repair of hiatus hernias.

Table 3 Results on recent series of hiatal hernia repair with or without mesh
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At this time, the decision to carry out a mesh cruroplasty rather than a direct closure after repairing a hiatal hernia is based on personal experience, and additional randomized studies on standardized use of reinforcement procedures are needed. We have so far chosen to perform only primary closures and complete an anterior gastropexy in patient with type III or IV hernia. In our series, we had a very low recurrence rate (13.1%) considering that all patients had a radiological follow-up. Though no prospective randomized studies have been conducted to demonstrate that anterior gastropexy reduces the recurrence rates, Ponsky et al. [29] have encouraged its use to reduce reherniation in both open and laparoscopic paraesophageal hernia repair, and no radiological or clinical recurrence were detected in their series though the mean follow-up was rather short (21 months, range 3–24 months). The opposing pressures in the abdomen and chest give rise to a constant tendency of the stomach to reherniate into the mediastinum. Fixing the stomach anteriorly to the abdominal wall should prevent this from happening, as well as helping to keep the stomach in its anatomic position if the crural suture fails. In the absence of prospective randomized trials, no final conclusion can be drawn on the efficacy of anterior gastropexy. However, the low recurrence rate in our study, even if in patients with gastropexy, suggests that routine anterior gastropexy may afford a better outcome than was previously reported in other laparoscopic series, so we strongly support this surgical expedient.

Another often discussed issue concerns the need for antireflux surgery in hiatal hernia repair, and which type of procedure works best. The extensive dissection required to obtain a quite long esophageal segment in the abdomen can make the gastroesophageal junction fail, resulting in postoperative reflux symptoms. A number of authors [16, 36] have reported an incidence of reflux symptoms in up to 47% of patients whose repair did not include any kind of fundoplication, and a variable percentage of patients may also complain of reflux symptoms already preoperatively (like more than 80% of the patients in our series). It has been suggested that a fundoplication might reduce the recurrence rate by fixing the stomach in the abdomen, but this has not been demonstrated prospectively. We performed an antireflux procedure in all the cases with a good control of reflux symptoms. Bearing these considerations in mind, we recommend that an antireflux procedure should always be associated with hiatal hernia repair. At present, the high rate of hernia recurrences is considered as the most common cause of long-term failure after laparoscopic repair, and [5–7] recurrence rates up to 42% are still being reported (even in recent literature), especially in case of large hiatal hernias. Based on the data collected in our study, the risk of recurrence can be reduced by complying with several crucial surgical principles, e.g., complete sac excision, appropriate crural closure and routine use of antireflux procedure and gastropexy. Patient satisfaction in our series also seemed quite high (91%). So the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.