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HIATAL HERNIA DEFECTS AND THE USES OF MESH VERSUS HUMAN GRAFTS

BY DIANE BROWN R.N., B.S.N.  

               The purpose of this Medical Research Review is to present results of current studies evaluating the postoperative results of Hiatal Hernia defects, with special emphasis on the recurrence rate and reflux after surgery comparing the use or not of mesh reinforcement.

               Hiatal Hernia is a structural defect in which a weakened diaphragm allows a portion of the stomach to pass through the esophageal diaphragmatic opening (hiatus) into the chest when intra-abdominal pressure increases. (1) Normally, the esophagus or food tube passes down through the chest, crosses the diaphragm, and enters the abdomen through a hole in the diaphragm called the esophageal hiatus. Just below the diaphragm, the esophagus joins the stomach. In individuals with hiatal hernias, the opening of the esophageal hiatus (hiatal opening) is larger than normal, and a portion of the upper stomach slips up or passes (herniates) through the hiatus and into the chest. (3) Three types of hiatal hernia occur: sliding hernia (most common), paraesophageal (rolling) hernia, or mixed hernia, which includes features of both of the other two. In a sliding hernia, both the stomach and the gastroesophageal junction slip up into the chest so that the gastroesophageal junction is above the diaphragm. In a paraesophageal hernia, a part of the greater curvature of the stomach rolls through the diaphragm. (1) (Photos for examples can be provided). (1, 3)

               Causes of Hiatal Hernia can be due to muscle weakening of the diaphragm associated with: aging, esophageal carcinoma (cancer of the esophagus), kyphoscoliosis (a lateral curvature of the spine), trauma, certain surgical procedures, congenital (present at birth) diaphragmatic malformations, or intra-abdominal pressure. (1)

               In a sliding Hiatal Hernia, symptoms occur in the presence of an incompetent gastroesophageal sphincter (a circular muscle constricting the opening into the stomach). A patient may exhibit such symptoms such as pyrosis (heartburn), occurring 1 to 4 hours after eating and aggravated by increased intra-abdominal pressure, accompanied by regurgitation or vomiting or retrosternal (behind the sternum, the bone lying mid chest) or substernal (under the sternum) chest pain. This chest pain often occurs after meals or at bedtime and is aggravated by reclining, belching, and increased intra-abdominal pressure. In a Paraesophageal hiatal hernia, the patient is typically asymptomatic, although the hernia rarely causes the symptoms, it may be an anatomic component of gastroesophageal reflux disease (GERD). With GERD, the patient may have a feeling of fullness in the chest or pain resembling angina (chest pain). (1)

               Treatment includes therapy which attempts to modify or reduce the reflux by decreasing or changing the amount or quality of the stomach contents, by strengthening the gastroesophageal sphincter muscle using medications, or by decreasing the amount of reflux of the stomach juices through gravity, such as instructing the patient to sit up after meals. Antacids modify the fluid refluxed into the esophagus and are probably the best treatment for intermittent reflux. Medications called Histamine 2 blockers, such as Famotidine (Mylanta-AR, Pepcid, Pepcid AC, Pepcidine), also can decrease the fluid refluxed into the esophagus. Drug therapy to strengthen gastroesophageal sphincter tone may include cholinergic agents such as bethanechol (Duvoid, Myotonachol, Urabeth, Ulrocarb). Failure to control symptoms by medical means or onset of complications require surgical repair. A paraesophageal hiatal hernia, even one that causes no symptoms, needs surgical treatment because of the high risk of strangulation. (1) Techniques vary greatly but most create an artificial closing mechanism (hiatoplasty) at the junction of the esophagus and the stomach to strengthen the lower esophagus sphincter function. (1) A Nissen Fundoplication is a surgical procedure to treat gastroesophageal reflux (GERD) and hiatus hernia. Dr. Rudolph Nissen first performed the procedure in 1955. In a fundoplicaton, the gastric fundus (upper part) of the stomach is wrapped around the lower end of the esophagus and stitched into place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia. (5)  Laparoscopic (Abdominal exploration employing a type of endoscope called a laprascope) anti-reflux surgery, often called LARS, has been popular since 1991 as the approach for hernia repair. (4, 6) The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophageal reflux disease. (9, 16)  Crural Closure technique for closure of herniation is utilized, and is obtained with simple surgical closure of the two halves of the right crus, closed anterior to the esophagus. (8) Laparoscopic repair of a hiatal hernia has been associated with high recurrence rate of reflux. (5, 17, 18)  It has been recognized that failure of hiatal hernia closure, recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. (9, 11, 12, 14, 15, 16) The use of biologic or synthetic mesh to reinforce the herniation repair has been shown to reduce recurrence. (6, 9, 10, 11, 12, 13, 14, 15, 16, 17)

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