title: Laparoscopic management of large hiatus hernia: five-year cohort study and comparison of mesh-augmented versus standard crura repair.
abstract: To evaluate objective and subjective outcomes of patients undergoing laparoscopic repair of large hiatal hernia, either with or without resorbable mesh augmentation. The primary outcome of the study was anatomical recurrence rate as measured by endoscopy. Secondary outcomes were safety, efficacy, and long-term quality of life.
  
  
  
  This was an observational cohort study. Patients who underwent laparoscopic repair of large (≥5 cm) type III hiatal hernia were included. Criteria of exclusion were previously failed hiatus hernia repair and emergency procedures. Patients were stratified into mesh group (mesh-augmented crura repair plus fundoplication) and non-mesh group (standard crura repair plus fundoplication). Preoperative and postoperative symptoms were assessed using the GERD-HRQL questionnaire. Upper gastrointestinal endoscopy was routinely performed between 6 and 12 months postoperatively and was repeated over the follow-up every 1-2 years or as needed. Anatomical hernia recurrence was defined as the maximum vertical length of stomach being at least 2 cm above the diaphragm.
  
  
  
  A total of 84 patients, 41 in the mesh group and 43 in the non-mesh group, operated between October 2009 and October 2014, were included in the study. All surgical procedures were completed laparoscopically. The median follow-up was 24 (IQR 29) months. There were 12 endoscopic recurrences, 4 in the mesh group and 8 in the non-mesh group. The five-year recurrence-free probability was similar in the two groups, but an earlier failure rate was noted in the non-mesh group at 12 months (p = 0.299). Three of the 12 patients with anatomical recurrence were symptomatic but did not require a reoperation. Univariate Cox proportional hazard analysis indicated that Toupet fundoplication may reduce the recurrence rate compared to Nissen fundoplication. No mesh-related complications occurred.
  
  
  
  Laparoscopic repair of large hiatal hernia is effective and durable. Crura reinforcement with a resorbable synthetic mesh is safe and may protect from early anatomical recurrence.
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Asti
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Lovece
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy. luigi.bonavina@unimi.it.
authors.forename: Luigi
authors.initials: L
authors.lastname: Bonavina
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Pamela
authors.initials: P
authors.lastname: Milito
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Sironi
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Gianluca
authors.initials: G
authors.lastname: Bonitta
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097, San Donato Milanese, Milan, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Siboni
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006551:Hernia, Hiatal / Q000000981:diagnostic imaging / Q000601:surgery*; D059685:Herniorrhaphy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D013526:Surgical Mesh; D016896:Treatment Outcome
keywords: Crura repair; Fundoplication; GERD-HRQL questionnaire; Gastroesophageal reflux disease; Hiatal hernia; Mesh