Laparoscopic antireflux surgery and hiatal hernia repair: techniques and outcome

Abstract

Gastroesophageal reflux disease (GERD) is the most prevalent benign disorder of the upper gastrointestinal tract. For patients who suffer from PPI-refractory GERD, severe regurgitation or for those who are unwilling to take life-long medication, antireflux surgery is the treatment of choice. Despite excellent long-term reflux control, laparoscopic Nissen, or total fundoplication, is associated with an increased risk of developing troublesome side-effects, of which dysphagia and gas-related symptoms are the most important. Therefore, partial fundoplications have been developed, of which the 270 degree posterior and 180 degree anterior fundoplication are most frequently performed. Currently, there is a lack of data supporting possible superiority of one of these partial fundoplications with regards to the incidence of dysphagia and gas-related symptoms. An important cause of GERD is the presence of a hiatal hernia, or diaphragmatic hernia. For patients suffering from a symptomatic hiatal hernia, laparoscopic repair is considered the treatment of choice. Due to the repetitive stress exerted on the diaphragm, the development of a recurrent hiatal hernia is an important problem. Therefore, the use of either absorbable or non-absorbable mesh to reinforce the cruroplasty has been introduced. Despite the presence of several randomized clinical trials comparing the use of different types of mesh versus sutures, there appears to be insufficient evidence for the routine use of mesh in laparoscopic hiatal hernia repair. In this thesis, we describe the long-term outcome of laparoscopic fundoplication, and compare the mid-term outcome of 270 degree posterior and 180 degree anterior partial fundoplication. Furthermore, we analyze the outcome of patients identified with pathological esophageal acid exposure after laparoscopic fundoplication, with special emphasis on heartburn, dysphagia, and need for surgical reintervention. Regarding the surgical treatment of hiatal hernia, we studied the outcome of laparoscopic hiatal hernia repair using sutures versus sutures reinforced with non-absorbable mesh. Additionally, we analyzed the outcome of laparoscopic repair in specific groups of patients, and compared the incidence of hiatal hernia following open en minimally invasive esophagectomy.