Abstract:

Laparoscopic repair of giant hiatal hernia：A clinical analysis of 96 patients        CHEN Zhen, ZHAO Hong-zhi, WANG Zhen-yu, et al. Department of Mini-invasive Surgery, Tianjin Nankai Hospital, Tianjin 300100, China
Corresponding author: CHEN Zhen, E-mail: cz@medmail.com.cn
Abstract    Objective    To estimate the effectiveness and safety of laparoscopic repair of giant hiatal hernia. Methods  The clinical data of 96 patients with giant hiatal hernia performed laparoscopic repair between January 2006 and July 2016 in Department of Mini-invasive Surgery,Tianjin Nankai Hospital were analyzed retrospectively. Primary hiatal closure was performed in 33 patients, and the hiatus was reinforced with mesh strips in 63 patients. A total or partial fundoplication was added in 84 patients. Results    All the 96 patients were treated by laparoscopy successfully. No conversion occurred. The mean operative time was（95.8±13.1）min for primary hiatal closure patients and（101.4±15.6）for mesh repair patients (P=0.0814). The average operative blood loss was（77.5±21.3）mL for primary hiatal closure patients and（79.6±24.5）mL for mesh repair patients (P=0.6769). The mean postoperative hospital stay was（5.4±4.3）d for primary hiatal closure patients and（5.5±3.7）d for mesh repair patients (P=0.9151). Early postoperative complications occurred in 6.1%（2/33）for primary hiatal closure patients and 9.5%（6/63）for mesh repair patients (P=0.71). Eighty-five of the 96 patients (88.5%) were available for following-up,among which there were 28 patients in primary hiatal closure group and 57 in the mash repair group, and the mean follow-up time was  56.3 months(range 6-120 months). Altogether, recurrence symptoms and developed new symptoms were demonstrated in 16 patients. Sour regurgitation recurrence occurred in 17.9%（5/28）of primary hiatal closure patients and 3.5%（2/57）of mesh repair patients（P=0.0364）, dysphagia occurred in 0（0/28）of primary hiatal closure patients and 15.8%（9/57）of mesh repair patients（P=0.0269）. 85.7%（24/28）of primary hiatal closure patients and 82.5%（47/57）of mesh repair patients satisfied with the outcome of operation（P=1）. Among 63 mesh repair patients,“O”shape mesh was performed in 29 patients and“U”shape mesh in 34 patients. Early postoperative complications occurred in10.3%（3/29）of“O”shape mesh group and 8.8%（3/34）of “U”shape mesh group (P=1).Also, 25 cases repaired with “O”shape mesh and 32 cases with “U”shape mesh were followed up for 97（71-120）months and 29（6-68）months. Sour regurgitation recurrence occurred in 4.0%（1/25）of“O”shape mesh group and 3.1%（1/32）of“U”shape mesh group（P=1）. Dysphagia occurred in 24.0%（6/25）of“O”shape mesh group and 9.4%（3/32）of“U”shape mesh group（P=0.1606）. Six cases of esophageal stenosis confirmed by endoscopy in 4 cases with “O”shape mesh and 2 cases with “U”shape mesh. The difference was not statistically significant（P=0.3883） Conclusion    Laparoscopic repair for giant hiatal hernia is safe and reliable. Mesh repair can reduce the recurrence rate but accompanied with risk of complication of dysphagia and mesh migration. Mesh should be used at surgeon discretion of indication, suitable description and optimized mesh placement to reduce the complication related. Appropriate fundoplication and esophageal lengthening could improve the outcome.

Key words: hiatal hernia, laparoscope, hernia repair, fundoplication, mesh

摘要：

目的    评价腹腔镜疝修补术治疗巨大食管裂孔的效果及安全性。方法    回顾性分析2006年1月至2016年7月天津市南开医院采用腹腔镜疝修补手术治疗的96例巨大食管裂孔疝病人资料，其中33例未使用补片，63例使用补片修补，84例同时行不同类型的胃底折叠术。结果    96例均完成腹腔镜手术，无中转开放病例。非补片组和补片组的手术时间分别为（95.8±13.1）min和（101.4±15.6）min（P=0.0814），术中出血量分别为（77.5±21.3）mL和（79.6±24.5）mL（P=0.6769），术后住院时间分别为（5.4±4.3）d和（5.5±3.7）d （P=0.9151），近期术后并发症发生率分别为6.1%（2/33）和9.5%（6/63）（P=0.71），差异均无统计学意义。85例获得长期随访（非补片组28例，补片组57例），随访率为88.5%（85/96），随访时间为56.3个月（6个月至10年）。16例症状复发或出现新的症状，非补片组和补片组的反酸复发率分别为17.9%（5/28）和3.5%（2/57）（P=0.0364），吞咽困难发生率分别为0（0/28）和15.8%（9/57）（P=0.0269），差异有统计学意义。手术结果满意率分别为85.7%（24/28）和82.5%（47/57），差异无统计学意义（P=1）。63例使用补片病人中，29例为“O”形补片，34例为 “U”形补片，两组近期并发症发生率为10.3%（3/29）和8.8%（3/34）（P=1），两组分别有25例和32例获得长期随访，随访时间分别为97（71～120）个月和29（6～68）个月。反酸复发率分别为4.0%（1/25）和3.1%（1/32）（P=1），吞咽困难发生率分别为24.0%（6/25）和9.4%（3/32）（P=0.1606），差异均无统计学意义。6例经胃镜证实的食管狭窄中4例为O形补片，2例为U形补片，差异无统计学意义（P=0.3883）。结论    腹腔镜疝修补术治疗巨大食管裂孔疝具有安全性高、疗效可靠的特点。应用补片能减少裂孔疝复发，但存在并发远期吞咽困难、补片移位的风险。把握补片使用指征、选择适宜补片、优化补片放置方式可降低相关并发症发生率；恰当的选择胃底折叠术式、正确处理短食管可提高手术疗效。

关键词: 食管裂孔疝, 腹腔镜, 疝修补术, 胃底折叠术, 补片