Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy

There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4-9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both.

Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4-27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs.

In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.