RESUMO
The use of mesh in laparoscopic hiatal hernia repair (LHHR) remains controversial. The aim of this systematic review was to determine the usefulness of mesh in patients with large hiatal hernia (HH), obesity, recurrent HH, and complicated HH. We performed a systematic review of the current literature regarding the outcomes of LHHR with mesh reinforcement. All articles between 2000 and 2020 describing LHHR with primary suturing, mesh reinforcement, or those comparing both techniques were included. Symptom improvement, quality of life (QoL) improvement, and recurrence rates were evaluated in patients with large HH, obesity, recurrent HH, and complicated HH. Reported outcomes of the use of mesh in patients with large HH had wide variability and heterogeneity. Morbidly obese patients with HH should undergo a weight-loss procedure. However, the benefits of HH repair with mesh are unclear in these patients. Mesh reinforcement during redo LHHR may be beneficial in terms of QoL improvement and hernia recurrence. There is scarce evidence supporting the use of mesh in patients undergoing LHHR for complicated HH. Current data are heterogeneous and have failed to find significant differences when comparing primary suturing with mesh reinforcement. Further research is needed to determine in which patients undergoing LHHR mesh placement would be beneficial.
Assuntos
Hérnia Hiatal , Laparoscopia , Obesidade Mórbida , Hérnia Hiatal/cirurgia , Herniorrafia , Humanos , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Qualidade de Vida , Recidiva , Estudos Retrospectivos , Telas Cirúrgicas , Resultado do TratamentoRESUMO
BACKGROUND: Giant paraesophageal hernias have a surgical indication in case of symptoms. Since twenty years ago robot-assisted repair was incorporated to overcome the limitations of the laparoscopic surgery, and to offer new advantages. OBJECTIVE: To report the experience on repairing giant paraesophageal hernias assisted by robot in a fourth level hospital in Bogotá, Colombia, Shaio Clinic. METHOD: Retrospective and descriptive study of five cases of giant paraesophageal hernia type III or IV, taken to robotic correction during August 2016 to June 2018. Evaluation of post-surgery outcomes. RESULTS: Five paraesophageal robot-assisted repair were performed. Mean surgical time was 146 minutes, one conversion to open surgery, the average intraoperative bleeding was 100 mL, hospital stay time of 2.2 days. Morbidity, mortality and recurrence percentages in the short time were equal to 0%. CONCLUSIONS: Robot-assisted repair of giant paraesophageal hernias, has shown advantages that overcome the limitations of the laparoscopic approach such as dissections in difficult-to-reach angles, increased accuracy, ergonomics, three-dimensional, and closer view of the workspace. In addition, robot-assisted repair promotes better surgical and postoperative outcomes; these advantages have been demonstrated mainly in the repair of giant paraesophageal hernias.
ANTECEDENTES: Las hernias paraesofágicas gigantes tienen indicación quirúrgica en caso de ser sintomáticas. Hace 20 años se incorporó la reparación asistida por robot debido a las ventajas que ofrece sobre las limitantes de la laparoscopia. OBJETIVO: Reportar la experiencia en reparación de hernias paraesofágicas gigantes asistida por robot en un hospital de cuarto nivel en Bogotá, Colombia, Fundación Clínica Shaio. MÉTODO: Estudio retrospectivo, descriptivo, de cinco casos de hernia paraesofágica gigante tipo III o IV, llevados a corrección robótica, de agosto de 2016 a junio de 2018, con evaluación de los desenlaces posoperatorios. RESULTADOS: Cinco pacientes fueron sometidos a reparación asistida por robot, el tiempo quirúrgico fue de 146 minutos, se realizó una sola conversión a cirugía abierta, la media de sangrado fue de 100 ml, el tiempo de estancia hospitalaria de 2.2 días, y los porcentajes de morbilidad, mortalidad y recurrencia a 1 año fueron del 0%. CONCLUSIÓN: La reparación de este tipo de hernias asistida por robot ha mostrado ventajas sobre el abordaje laparoscópico, como realizar disecciones en ángulos de difícil acceso, precisión aumentada, ergonomía y vista tridimensional y más cercana del espacio de trabajo. Además, promueve mejores desenlaces quirúrgicos y posoperatorios, ventajas evidenciadas principalmente en la reparación de hernias paraesofágicas gigantes.
Assuntos
Hérnia Hiatal , Laparoscopia , Robótica , Colômbia , Hospitais , Humanos , Estudos RetrospectivosRESUMO
Reconstruction of the digestive tract is a surgical challenge; we propose a novel and successful alternative using a large vascularized pedicled jejunum anastomosed to the cervical esophagus in an emergency situation. A 65-year-old female patient in follow-up due to a gigantic type IV paraesophageal hernia, whom underwent surgical hernial defect correction, had friable gastric tissue and esophageal lesions that forced an urgent esophagojejunostomy. Immediate post-operative recovery had no incidents and during the outpatient follow-up no complications were reported. This case report represents a paradigm change in the impossibility of raising the vascularized pedicled jejunum to the neck in an emergency situation.
La reconstrucción del tracto digestivo es un reto quirúrgico. Proponemos una alternativa novedosa y exitosa utilizando un gran yeyuno pediculado vascularizado anastomosado al esófago cervical en situación de emergencia. Una paciente de 65 años en seguimiento por una hernia paraesofágica tipo IV requirió corrección quirúrgica del defecto herniario; tenía tejido gástrico friable y lesiones esofágicas que forzaron una esofagoyeyunostomía urgente. La recuperación posoperatoria inmediata no tuvo incidentes y el seguimiento ambulatorio no mostró complicaciones. Este reporte de caso rompe el paradigma de la imposibilidad de ascender el yeyuno pediculado vascularizado al cuello en una situación de emergencia.
Assuntos
Esofagoplastia , Hérnia Hiatal , Idoso , Anastomose Cirúrgica , Feminino , Gastrectomia , Hérnia Hiatal/cirurgia , Humanos , Jejuno/cirurgiaRESUMO
Despite paraesophageal hernias (PEH) being a common disorder, several aspects of their management remain elusive. Elective surgery in asymptomatic patients, management of acute presentation, and other technical aspects such as utilization of mesh, fundoplication or gastropexy are some of the debated issues. The aim of this study was to review the available evidence in an attempt to clarify current controversial topics. PEH repair in an asymptomatic patient may be reasonable in selected patients to avoid potential morbidity of an emergent operation. In acute presentation, gastric decompression and resuscitation could allow to improve the patient's condition and refer the repair to a more experienced surgical team. When surgical repair is decided, laparoscopy is the optimal approach in most of the cases. Mesh should be used in selected patients such as those with large PEH or redo operations. While a fundoplication is recommended in the majority of patients to prevent postoperative reflux, a gastropexy can be used in selected cases to facilitate postoperative care.
Assuntos
Gastropexia , Hérnia Hiatal , Laparoscopia , Fundoplicatura , Hérnia Hiatal/cirurgia , Humanos , Estudos Retrospectivos , Telas CirúrgicasRESUMO
Paraesophageal hernia (PEH) repair is one of the most challenging upper gastrointestinal operations. Its high rate of recurrence is due mostly to the low quality of the crura and size of the hiatal defect. In an attempt to diminish the recurrence rates, some clinical investigators have begun performing mesh-reinforced cruroplasty with nonabsorbable meshes like polypropylene or polytetrafluoroethylene. The main problem with these materials is the occurrence, in some patients, of serious mesh-related morbidities, such as erosions into the stomach and the esophagus, some of which necessitate subsequent esophagectomy or gastrectomy. Absorbable meshes can be synthetic or biological and were introduced in recent years for PEH repair with the intent of diminishing the recurrence rates observed after primary repair alone but, theoretically, without the risks of morbidities presented by the nonabsorbable meshes. The current role of absorbable meshes in PEH repair is still under debate, since there are few data regarding their long-term efficacy, particularly in terms of recurrence rates, morbidity, need for revision, and quality of life. In this opinion review, we analyze all the presently available evidence of reinforced cruroplasty for PEH repair using nonabsorbable meshes (synthetic or biological), focusing particularly on recurrence rates, mesh-related morbidity, and long-term quality of life.