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Trattamento laparoscopico dellernia iatale con
protesi composita
M. Casaccia, P. Torelli, F. Panaro, D. Cavaliere,
U. Valente
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Trattamento laparoscopico dellernia iatale con
protesi composita

• Theoretical vectorial and geometrical study
  Phyisiological tension-free hiatoplasty

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Trattamento laparoscopico dellernia iatale con
protesi composita

• Anatomical study on fresh cadavers
• A-shaped mesh

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Trattamento laparoscopico dellernia iatale con
protesi composita

• Material composite PTFE polypropylene
  prothesis (Bard? Composix? Mesh)
• The smooth surface and the sub-micronic
  pore size of the PTFE side of the mesh minimize
  tissue attachment and therefore minimize
  adhesions and risk of bowel perforation

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Trattamento laparoscopico dellernia iatale con
protesi composita

• Clinical Reports
• Period September 2000 - October 2001
• 8 patients received laparoscopic reparation of
  large (type II or III) hiatal hernias
• Prothesis A-shaped polypropylene-PTFE mesh.
• Sex 2 men and 6 women.
• Average age was 65 years (range 35-78 ys.)
• Average weight was 58 Kg (range 48-81 Kg). The
  patients presented with Non-typical GERD symptoms
  from 4 months to 16 years in duration.
• Preoperative assessment upper GI endoscopy,
  esophageal manometry, 24-h pH monitoring and
  barium swallow.
• Concomitant esophagitis was found in 5 patients
  and impaired esophageal peristalsis in 2
  patients. Two patients had concomitant
  gallbladder disease.

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Trattamento laparoscopico dellernia iatale con
protesi composita
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Trattamento laparoscopico dellernia iatale con
protesi composita

• Results
• In 5 cases of concomitant GERD we associated a
  fundoplication tailored according to oesophageal
  motility and to the degree of hypotonia of the
  LES.
• All the procedures were completed
  laparoscopically.
• In all cases the lenght of the hiatal defect was
  larger than 6 cm.
• The average operative time was 120 minutes
  (range 90-180 min).
• A perioperative complication occurred in one
  patient who developed pneumonia at the seventh
  p.o. day, treated medically.
• In two patients with concomitant gallbladder
  disease, a cholecystectomy was associated without
  increase in trocar number.
• Oral feeding was allowed from the second to third
  p.o. day.
• Average postoperative hospital stay was 4 days
  (range 3-6 days). Return to working activity was
  achieved after 7 to 20 days.

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Trattamento laparoscopico dellernia iatale con
protesi composita

• Results
• Postoperative anatomical assessment was studied
  with a barium swallow on the 7th p.o. day and
  showed the absence of recurrence and the correct
  positioning of the stomach.
• At a mean follow-up of 8 months (range3-15
  months) two patients had persistent dysphagia
  lasting up to three months and finally resolved
  with medical treatment. One patient developed an
  umbilical hernia at a trocar site after a 9-month
  follow-up.
• An overall satisfactory outcome was achieved in
  all patients (VAS Visual Analogic Score, scale
  0-10). Average score was 8,5 (range 7-10).

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Trattamento laparoscopico dellernia iatale con
protesi composita

• Conclusions
• PRO
• The A-shaped mesh perfectly fits to the hiatal
  region and its thickness doesnt represent an
  obstacle to the handling and placement.
• Good tolerance of the patient to the prosthetic
  material.
• The A-shaped mesh minimize tissue attachment,
  adhesions and risk of bowel perforation
  (superiority of Composite meshes to the one-layer
  meshes for the reparation of large incisional
  hernias)
• CONS
• Initial series with a short follow-up
• Lack, from a technical point of view, of a
  classification based on the dimensions of the
  hiatal defect and not only on the classical
  physiopathologic mechanisms (type I,II,III).
• Amid P.K, et al. (1995) Ann Chir49539-42
• Moreno-Egea A, et al. (2001). Surg Laparosc
  Endosc Percutan Tech 11103-6.