Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area

The closure of the hiatal crura has proven to be a fundamental issue in laparoscopic antireflux surgery. In particular, the use of prosthetic meshes for crural closure results in a significantly lower rate of postoperative hiatal hernia recurrence with or without intrathoracic migration of the fundic wrap. The aim of the present study was to evaluate different methods of crural closure depending on the size of the hiatal defect by measuring the hiatal surface area.

Fifty-five consecutive patients (mean age = 53 years) with symptomatic gastroesophageal reflux disease (GERD) were scheduled for laparoscopic antireflux surgery (LARS) in our surgical unit. Intraoperatively, the length, breadth, and diameter of the hiatal defect was measured using an endoscopic ruler. In every patient, the hiatal surface area (HSA) was calculated using an arithmetic formula. Depending on the calculated HSA, hiatal closure was performed by (1) simple sutures, (2) simple sutures with a 1 x 3-cm polypropylene mesh, (3) simple sutures with dual Parietex dual mesh, or (4) "tension-free" polytetrafluoroethylene BARD Crurasoft mesh.

Twenty-six patients (47.2%) underwent laparoscopic 360 degree "floppy" Nissen fundoplication. The remaining 29 patients (52.8%) with esophageal body motility disorder underwent laparoscopic 270 degree Toupet fundoplication. Mean calculated HSA in all patients was 5.092 cm2. Thirty-two patients (58.2%) with a smaller hiatal defect (mean HSA = 3.859 cm2) underwent hiatal closure with simple sutures (mean number of sutures: = 2.0). In 12 patients (21.8%) with a mean HSA of 7.148 cm2, hiatal closure was performed with a 1 x 3-cm polypropylene mesh in addition to simple sutures. Five patients with a mean HSA of 6.703 cm2 underwent hiatal closure with Parietex mesh, and in the remaining six patients, who had a mean HSA of 8.483 cm2, the hiatus was closed using BARD Crurasoft mesh. For a mean followup period of 6.3 months, only one patient (1.8%) developed a postoperative partial intrathoracic wrap migration.

Measurement of HSA with subsequent tailoring of the hiatal closure to the hiatal defect is an effective procedure to prevent hiatal hernia recurrence and/or intrathoracic wrap migration in laparoscopic antireflux surgery.