360 degrees laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease

Background: Since laparoscopic Nissen fundoplication was first described by Cuschieri in 1989 and later by Dallemagne in 1991, this procedure has been widely employed for the treatment of symptomatic gastroesophageal reflux d isease (GERD) and/or hiatal hernia. However, a relatively high incidence (7 -11%) of intrathoracic Nissen valve migration/paraesophageal hernia followi ng laparoscopic fundoplication has recently been reported. Methods: Between November 1992 and August 1995, 65 consecutive patients wit h severe GERD and/or hiatal hernia underwent laparoscopic 360 degrees fundo plication. In nine of these 65 (13.8%) patients, an intrathoracic Nissen va lve migration had occurred within 4 months. Six of these patients were symp tomatic and were again submitted to the laparoscopic intervention. Videotap es of both the first and second operation were reviewed. In all cases, it w as apparent that, at the first operation, closure by stitches of the hiatus was under tension, and at the second operation, the muscle fibers of the r ight crus were disrupted, probably due to the tension between the suture ma rgins during the inspiratory movements of the diaphragm. These findings pro mpted us to perform an effective tension-free closure of the hiatus. A poly propylene mesh (3 x 4 cm) was placed on the hiatus behind the esophagus and fixed with eight metallic agraphes (2 + 2 on the superior edge and 2 + 2 o n the lateral sides of the right and left cruses). Results: Between August 1995 and February 1998, the technique, complete wit h 360 degrees fundoplication, was used for 67 patients with GERD. At mean f ollow-up of 22.5 months (range, 1-30), there was no evidence of postoperati ve paraesophageal hernia or complications related to the use of the mesh. Conclusions: This tension-free hiatoplasty seems to be an effective solutio n to prevent postoperative paraesophageal hernia in patients undergoing ant ireflux laparoscopic surgery. However, longer follow-up is still needed.