World J Surg (2008) 32:329 DOI 10.1007/s00268-007-9367-x

Reply Ilknur Kepenekci Æ Ahmet Gokhan Turkcapar

Published online: 11 December 2007 Ó Socie´te´ Internationale de Chirurgie 2007

The available data regarding prosthetic hiatal repair shows that polypropylene mesh is accompanied by a low incidence of recurrence, but appropriate surgical technique is of paramount importance. A number of techniques have been published, and different shapes of mashes and different techniques of placement have been proposed. C-shaped, U-shaped, A-shaped, circular, or keyhole collarshaped meshes have been used successfully to provide a buttress for hiatoplasty [1–4]. Nevertheless, there is still no consistent agreement about the mesh material or the shape of the mesh. Some animal studies show that at reoperation there is a fair amount of fibrosis and contraction of tissue at the hiatus. Placement of a circumferential prosthesis above the fundoplication may create dysphagia, and direct contact with the esophagus has a potential to cause erosion [5]. Special attention should be paid to avoiding any contact between the mesh and esophagus because of the risk of erosion of a foreign body into the esophagus or transmural migration of surgical material into the esophagus [6, 7]. The fibrotic reaction caused by the mesh reinforces the crural closure and also plays a role in the adhesion of fundoplication. A small sized mesh placed on the primary suture repair is sufficient to achieve reinforce the crural closure, and a large mesh is not needed. A very large mesh, insufficient fixation, and direct contact with esophagus may lead migration of the mesh.

I. Kepenekci (&)
A. G. Turkcapar Department of Surgery, Ankara University School of Medicine, AUTF Ibni Sina Hastanesi Ek Bina K4 Samanpazary´, 06100 Ankara, Turkey e-mail: [email protected]

In our institution, we have been using prosthetic material routinely for reinforcement of the hiatal crura since July 2002. An onlay buttress placed over the primary suture repair is performed routinely regardless of the size of the hiatal hernia. The hiatus is closed using a 1 9 3 cm U-shaped polypropylene mesh. To present a proposal for avoiding the potential complications of mesh reinforcement, we use a small mesh placed so as to have no contact with the esophagus. The mesh is placed to cover the diaphragmatic crura with the open end of the U pointing anteriorly, and it is in contact only with the fundoplication site in an area probably smaller than 1 cm2. We secure the mesh to the diaphragmatic crura using six to eight staples with Protack (Autosuture). We think that this is a safe method, and it is probably the easiest way to fix the mesh. There has been no evidence of any mesh-related complications, in our series of patients. The available data show that prosthetic hiatal repair is safe and effective. It seems that potential complications are not inherent in the use of mesh but rather are the result of the surgical technique. References 1. Basso N, De Leo A, Genco A et al. (2000) 3600 laparsocopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg Endosc 14:164–169 2. Edelman DS (1995) Laparoscopic paraesophageal hernia repair with mesh. Surg Laparosc Endosc 5:32–37 3. Champion JK, Rock D (2003) Laparoscopic mesh cruroplasty for large paraesophageal hernias. Surg Endosc 17:551–553 4. Paul MG, De Rosa RP, Petrucci PE et al. (1997) Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc 11:303–307 5. Edelman DS (1995) Laparoscopic paraesophageal hernia repair with mesh. Surg Laparosc Endosc 5:32–37

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330 6. Arendt T, Stuber E, Monig H et al. (2000) Dysphagia due to transmural migration of surgical material into the esophagus nine years after Nissen fundoplication. Gastrointest Endosc 51:607–610

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World J Surg (2008) 32:329–330 7. Zilberstein B, Eshkenazy R, Pajecki D et al. (2005) Laparoscopic mesh repair antireflux surgery for treatment of large hiatal hernia. Dis Esophagus 18:166–169