Necessity of fundoplication and mesh in the repair of the different types of paraesophageal hernia

Background : The management of paraesophageal hernia (PEH) has changed significantly since the introduction of laparoscopic surgery in the 1990's. This study aims to explore the need of a Nissen fundoplication or a posterior gastropexy and the use of mesh reinforcement in the surgical repair of PEH. Patients and methods : Seventy-three patients with a symptomatic and documented PEH type II, III or IV were included in this retrospective study. The following data were collected: type of PEH, surgical procedure, complications, length of hospital stay, recurrences, time to recurrence, type of PEH recurrence and treatment of recurrent PEH. Results : All 73 patients underwent laparoscopic surgery without any conversion to open surgery. In 80% a posterior gastropexy was performed, while the remaining 20% suffered from GERD- symptoms and were treated with a Nissen fundoplication. In 18% of the patients a mesh was used as reinforcement of the repair. The surgical repair differed significantly according to the type of PEH. Fourteen percent of the patients suffered from a postoperative complication, pneumothorax and dysphagia being the most frequent. There were no perioperative deaths. The recurrence rate was 22% with a median time to recurrence of 12 months. Conclusion : Laparoscopic PEH repair is a safe and efficacious procedure with no mortality and minimal early morbidity. The surgical repair of PEH should be adjusted to the type of PEH. However, up until now the literature fails to produce clear guidelines on when to perform a gastropexy or Nissen fundoplication and which patients might benefit from a mesh reinforcement. (Acta gastroenterol. belg., 2019, 82, 251-256).