Management of the Difficult Hiatus

Closing the crura in reoperative surgery can be challenging. The first and most important step in repairing hiatal defects is to avoid destroying the crural fibers while performing the initial dissection of the area. Spending the extra time to dissect this area carefully will be rewarded later in the operation when it becomes time to close the hiatus. On rare occasions, the crura will be very fibrotic creating esophageal obstruction at the hiatal level. This problem is easily remedied by dividing a portion of the

MANAGING FAILED ANTI-REFLUX THERAPY

crus. The most common problem, however, is dealing with a large hiatal defect. In most instances,primary closure can be accomplished. The stoutest crural fibers are the posterior fibers so sutures should be placed deeply to encompass them. In laparoscopic reoperations, the intraabdominal pressure should be lowered to 8 or 10mmHg in order to diminish the diaphragmatic stretch.

There are situations in which primary closure seems impossible. When this occurs, the options are to make a relaxing incision in the diaphragm and close this defect with prosthetic material or to place prosthetic material directly into the hiatus. Surgical dogma has been that placement of prosthetic material in the hiatus would lead to erosion of the foreign body into the esophagus. In the laparoscopic era, however, there are numerous reports claiming both the safety and benefit of using prosthetic material for difficult hiatal closures. Although there is relatively limited follow-up, the use of mesh at the esophageal hiatus has been associated with significantly reduced recurrence rates with minimal morbidity. Laparoscopic refundoplica-tion with a circular polypropylene mesh was performed in 24 patients with intrathoracic her-niation of the wrap. Although one patient had severe dysphagia requiring pneumatic dilation postoperatively, all patients had good to excellent functional outcome at 1 year follow-up.11 Prosthetic material may be useful in reinforcing the crural closure, particularly if the hiatal disruption is large or if the tissue is less than robust. The use of polytetrafluoroethylene mesh in conjunction with a Nissen fundoplication was investigated in patients with a hiatal defect >8 cm. With at least 1 year follow-up, this prospective, randomized controlled study demonstrated that 8 of the 36 patients undergoing simple cruroplasty developed recurrences, whereas none of the 36 patients with polyte-trafluoroethylene mesh recurred.20 This benefit of prosthetic reinforcement has been observed in multiple other studies.10,20,21 Although there has been concern regarding the possibility of erosion of the mesh into the stomach or esophagus, these fears have not materialized—at least in the short term. Most recently, biodegradable small intestinal submu-cosal patches have become available and appear to hold promise as an adjunct to closing large hiatal defects.

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