Laparoscopic refundoplication with prosthetic hiatal closure for recurrent hiatal hernia after primary failed antireflux surgery

Background: One of the most frequent complications after laparoscopic antireflux surgery is estimated to be the intrathoracic herniation of the wrap into the chest. Therefore, in up to 5% of patients, revisional surgery is necessary. Hypothesis: Patients who undergo laparoscopic refundoplication for postoperative intrathoracic wrap herniation using a circular polypropylene mesh for hiatal closure have a good to excellent functional outcome, during a complete follow-up of 1 year. Design: Prospective nonrandomized trial of a consecutive sample. Setting: University-affiliated community hospital. Patients: Twenty-four patients undergoing laparoscopic refundoplication for persistent or recurrent symptoms of gastroesophageal reflux disease as a result of postoperative intrathoracic wrap migration. Intervention: All patients underwent laparoscopic refundoplication with a circular polypropylene mesh for hiatal closure. Main Outcome Measures: Recurrences, complications, postoperative lower esophageal sphincter pressure, DeMeester score, esophagogastroduodenoscopy results, and barium swallow results. Results: All refundoplications were completed laparoscopically. There were no intraoperative complications. Twenty-one patients underwent laparoscopic Nissen fundoplication; in 3 patients, a laparoscopic Toupet fundoplication was performed. Previous antireflux procedures included an open Nissen fundoplication (n = 5), a laparoscopic Nissen fundoplication (n = 15), and a laparoscopic Toupet fundoplication (n = 4). Postoperatively, one patient had severe dysphagia and had to undergo pneumatic dilatation once. During a follow-up of 1 year after surgery, no patient developed a recurrent hiatal hernia, with or without intrathoracic wrap herniation. The mean lower esophageal sphincter pressure increased significantly (P<.01) at 3 months (12.2 mm Hg) and 1 year (11.9 min Hg) after refundoplication. The mean DeMeester score decreased significantly (P<.01) from 50.5 points preoperatively to 16.0 points at 3 months and 14.7 points at 1 year after refundoplication. Conclusion: Laparoscopic refundoplication with prosthetic hiatal closure is a safe and effective procedure for preventing recurrent intrathoracic wrap herniation, with good to excellent functional outcome for a complete follow-up of 1 year.