Necessity of fundoplication and mesh in the repair of 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 front 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 front a postoperative complication, pneumothorax and dysphagia being the most frequent. There were no perioperatise 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 front a mesh reinforcement.