16- Prophylactic Laparoscopic Hiatoplasty Technique

Introduction:

Laparoscopic fundoplication has been confirmed as an effective long-term therapy in the treatment of gastroesophageal reflux disease, but has been reported that various factors and stressors¹ on the diaphragm can significantly promote the failure of intervention. Different surgical techniques with synthetic nonabsorbable and biological material were used to reinforce the hiatal area and reduce esophagus’ complications from the use of the mesh.² Moreover, the placement of this material in the hiatal area (usually performed with tacks or sutures) can be difficult and dangerous, which has led surgeons to be skeptical of this technical solution.

Materials and Methods:

In the adult population, after suturing the diaphragmatic pillar with a nonabsorbable material no. 0, we proceeded to the reinforcement hiatoplasty. We used a preformed 7×10-cm sheet of material known as synthetic bioabsorbable tissue regenerator material (BioA Tissue Reinforcement W. L. GORE & Associates, Inc.), which we recut to fit the area being treated. We placed it over the hiatal region, providing a single adherence point with a reabsorbable material in the central and lowest portion of the previously sutured diaphragmatic pillars, which is not considered necessary in all cases and is sometimes used to prevent displacement of the mesh while it is secured, facilitating the handling maneuvers. The reinforcement material is completely fixed using 1 mL of synthetic surgical glue (Glubran 2-GEM-CARDIOLINK) that can be applied from behind or on the synthetic tissue (in areas with more difficult access) because of its porous nature. The glue is applied to the most external area of hiatal region, so that the reinforcement material is directly in contact with the pillars in the central portion.

Results and Conclusions:

Our orientation in the surgical indication is an intent of prophylactic reinforcing the hiatal area in a simple way, minimizing the risk of esophageal and hiatal area injury, in patients with high probabilities of hernia recurrence (overweight-obesity, chronic respiratory disease, hiatus with weak musculature, small hiatal hernia, and patients with work activity that requires significant physical exertion). We use an absorbable autologous collagen-generating matrix (polyglycolic acid and trimethylene carbonate), backed by extensive experience in its use in other location and fixed with synthetic absorbable surgical glue (modified cyanoacrylic based), with an adequate bibliography of utilization to fix meshes in primary and incisional hernias with both open and laparoscopic techniques. The performance of the hiatoplasty intervention does not increase the total surgical time by more than 15 minutes, and initial results of our series show a promising solution for reducing the rate of hernia recurrence, with no complications or relapses to date.