The application of bioabsorbable prosthesis such as Surgisis (small intestinal submucosa, SIS), BioA Tissue Reinforcement (polglycolide or teimethylene carbonate) or AlloDerm (human acellular dermis) in hiatal hernia repair has been suggested to avoid mesh related complications, such as erosion or stricture[9, 13, 14]. In our study, we used a prosthesis made of bovine pericardium for the reinforcement, and this mesh has been widely used in inguinal and ventral hernia repair in China. However, the concern on using biological prosthesis is the weaker strength compared to synthetic material, and this might result in higher recurrence. A few recent studies have confirmed reliable outcomes with biological prosthesis for hiatal hernia repair[10, 14, 15]. In our study, including more than 90% of giant or paraesophageal hernia, there was no symptomatic recurrence during follow-up. The case of sliding hernia shown at the Upper GI series one year after operation did not need further medical intervention. This patient was an 83-year-old female with a giant hiatal hernia, and we were advised to perform the surgery for a shorter time with lower CO2 pressure by the anaesthetist during the procedure for the safety. Therefore, a simple crural closure was performed without fundoplication, and this could be the reason why the fundus slipped upwards.
In this study, we used NCBA medical glue for prosthesis fixation after crural closure, and the results were satisfactory. The manipulation was easy, and fixation was secure. Previous animal studies have confirmed the safety of chemical and biological adhesives for mesh fixation [16–19]. Moreover, clinical studies have shown that adhesives, both biological and chemical, are an effective means of mesh fixation in hernia repair and results are comparable to those of traditional techniques such as suture and tack devices [20–27]. However, the shortcomings of biological sealants (e.g., fibrin glue), which are expensive, provide a weak bond, are slow to apply, and are potentially allergenic, have limited their application, particularly in China [7]. For these reasons, Compont, an NBCA chemical adhesive, which is fast acting and provides good adhesive strength, is the preferred surgical adhesive used in China today [28]. The reason why additional suture fixation is needed is that the oesophageal hiatus is a very dynamic area with approximately 3,000 movements every day, therefore erosion, stricture or recurrence might happen with inadequate fixation[13]. However, without glue spray, the fixation needs more sutures, and therefore becomes more time consuming.
Proper mesh fixation is the key for the efficiency and the safety of hiatal hernia repair. Most surgeons currently use suture and some use tacks or staples for fixation. Both of these methods have their problems and do not allow strong, uniform, and immediate fixation of the mesh to the crural fibres. Having used the NCBA glue for mesh fixation in laparoscopic inguinal hernia repair since 2009 at our centre, we noticed that the fixation of the mesh was strong, immediate, and uniform[27]. On the other hand, the application of tacks at hiatus has been reported to cause serious complications such as cardiac tamponade and mortality [29]. As a result, tacker fixation has been strongly advised against by several surgeons[30]. In addition, the SAGES guidelines for management of hiatal hernia state that care should be taken about the mesh fixation technique. In particular, tacks can breach the aorta or pericardium when applied low on the left crus or anteriorly near the apex of the crura[30]. In comparison, medical glue fixation is safe without the risk of penetrating important organs. Furthermore, some studies reported that fixation by glue combined with suture is as strong as tacker[28].
In conclusion, biological mesh reinforcement of crural closure was safe and effective for repairing large hiatal hernias. Medical glue combined with suture can provide solid and secure fixation and can reduce the serious complications caused by fixation. The limitation of this study is that results from longer follow-up are still needed prior to the final conclusion.