1. A.O. dei Colli Monaldi Hospital NAPLES - ITALY HIGLY SPECIALISED HOSPITAL General and Laparoscopic Surgery Dept Chief: Prof. F. Corcione GERD: Surgical Complications Diego Cuccurullo

2. Surg Laparosc Endosc Percutan Tech. 2006 Oct;16(5):301-6. Review of outcome after laparoscopic paraesophageal hiatal hernia repair. Mehta SMehta S, Boddy A, Rhodes M.Boddy ARhodes M Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK. In total, 1415 patients underwent attempted repair (mean age 65.7 y) of which 94% underwent an antireflux procedure. There were 70 (5.3%) episodes of operative morbidity and 173 (12.7%) patients experienced postoperative complications. In 10 studies, radiologic follow-up was offered after a mean of 16.5 months. Of those undergoing contrast swallow 26.9% had evidence of anatomic recurrence. In conclusion, recurrence rates after laparoscopic repair seem to be high compared with earlier studies of open repair. The long-term consequences of anatomic recurrence are currently uncertain. OUTCOME IN THE LITERATURE

3. Midterm analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia E.M. Targarona et al.Surg Endosc 2004 “The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to estabilish technical alternatives that would ensure the durability of the repair”. RECURRENCE

4. RECURRENCE RANGING BETWEEN 0 AND 40% ON MIDTERM FOLLOW-UP “One interesting finding of our study is that a number of patients with recurrent radiological hernia remained asymptomatic. A small asymptomatic sliding hernia is considered of low importance, and the consensus is that further treatment is not necessary.”

5. Anatomical failure following laparoscopic antireflux surgery (LARS): does it really matter? Dunne N et al.Ann R Coll Surg Engl 2010 “The prevalence of some form of anatomical failure, as determined by increase in the interclip distance, is high at 6 months postoperatively following LARS. However, this not seem to correlate with a subjective recurrence of symptoms”. RECURRENCE

6. Laparoscopic hiatal hernia repair Long-term outcomes with the focus on the influence of mesh reinforcement Muller-Stich B.P. et al.Surg Endosc 2006 “Although challenging, LRHP is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement”. THE USE OF MESH

8. Laparoscopic repair of large tipe III hiatal hernia: objective follow-up reveals high recurrence rate. Hashemi M. et al.J Am Coll Surg 2000 Recurrence rate 42% RECURRENCE

9. Laparoscopic revisional fundoplication with circular hiatal mesh prosthesis: the long term results. Granderath FA. et al. World J Surg 2008 “Laparoscopy refundoplication for primary failed hiatal closure with the use of a circular mesh prosthesis is a safe and effective procedure to prevent hiatal hernia recurrence for short and mid-term follow-up”. THE USE OF MESH

10. Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study. Granderath FA. et al. Arch Surg 2005 “Laparoscopy Nissen fundoplication with prosthetic cruroplasty is an effective procedure to reduce the incidence of postoperative hiatal hernia recurrence and intrathoracic wrap herniation”. THE USE OF MESH

11. A prospective randomized trial of laparoscopic PTFE patch repair vs simple cruroplasty for large hiatal hernia. Frantzides CT. et al. Arch Surg 2002 “The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences”. RCT THE USE OF MESH

12. Postoperative results after laparoscopic approach for treatment of large hiatal hernias. Is mesh always needed? Is the addition of an antireflux procedure necessary? Braghetto I. et al. Int Surg 2010 “In conclusion, mesh reinforcement in patients with large tipe IV could prevent recurrent hiatal hernias, and an antireflux procedure must be performed in order to avoid postoperative acid reflux”. THE USE OF MESH

13. Paraesophageal hernia: clinical presentation, evaluation and management controversies. Schieman C. et al. Thorac Surg Clin 2009 “Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long term follow-up is required to determine wheter the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice”. THE USE OF MESH

14. Complications of mesh repair in hiatal hernia surgery: about 3 cases and review of the literature. De Moor V. et al. Surg laparosc Endosc Percut Aug 2012 “Primary repair of hiatal hernias is associated with high recurrence rate. The prostethic mesh to reinforce the crura seems to lead less recurrence rate. Unfortunately, the procedure is still controversial in regard of the possible complications that may occur.” THE USE OF MESH

15. Severe complications of laparoscopic mesh hiatoplasty for paraesophageal hernia. Zùgel N. et al. Surg Endosc 2009 “One patient developed a severe aortal bleeding after the laparoscopic mesh repair… Conclusions: in view of the described complication, there is still considerable controversy regarding the routine use of mesh. To increase safety, a composite mesh should be preferred”. SEVERE COMPLICATIONS

16. Erosion of a composite PTFE/ePTFE mesh after hiatal hernia repair Hazbroek EJ. et al. Surg Laparosc Endosc Percutan Tech 2009 SEVERE COMPLICATIONS

17. Late mesh migration through the stomach wall after laparoscopic using a dual-sided PTFE/ePTFE mesh Carpelan-Holmstrom M Hernia 2010 SEVERE COMPLICATIONS

18. PREOPERATIVE EVALUATION HHR CHEST X-RAY UPPER ENDOSCOPY ESOPHAGEAL 24-h PH MEASUREMENT BARIUM CONTRAST SWALLOW MANOMETRY

19. CHOICE OF THE PROCEDURE LES Esophageal manometryEsohageal motility Decreased pressure (<10 mmHg) Decreased lenght of the abdominal portion (<1cm) Decreased total lenght (<2 cm) HHR

20. 486 cases (March 1992- Sep 2012) Age: 22-78 years Sex: 218 F./168 M. Operative time: 70m. (35-230) Dor5 Nissen-Rossetti308 Toupet163 Mesh 68 Reoperations: 16 In our experience

21. INTRA: OUR EXPERIENCE Complications : 2 mediastinal & neck emphysema 1 gastric perforation 3 pleural injury 1 “lost needle syndrome” 2 splenic capsule injury (1 splenectomy) 1 pericardial tamponade 61 transient dysphagia 2 permanent dysphagia 1 strangulated paraesophageal early recurrent hernia 23 Recurrence 2 Mesh migration CONVERSIONS 0 POST: HHR

22. Recurrences: 37 cases Age: 28-78 years Sex: 15 F./12 M. Operative time: 110m. (80-260) Nissen-Rossetti30 Toupet6 Collis Toupet1  PTFE1  Composix8  Proceed19  Physio mesh2  Bio A6 In our experience

23. Complications  prosthetic esophageal migration13,7%  gastric paresis13,7%  Recurrence38,1%  Total615,5% Recurrences: 37 cases

31. GOOD RESULTS PROPER INDICATIONS PREOPERATIVE EVALUATION PERFECT SURGICAL TECHNIQUE (type of fundoplication) USE OF THE MESH WHEN INDICATED (paraesophageal, large hiatus, recurrence)

32. “Notre but d’entrevoir la survenue d’une chirurgie “physiologique” qui dans chaque cas particulier elimine le r.g.o. pathologique sans entrainer de troubles secondaires” J.L.LORTAT-JACOB 1973 (We aim to foresee the occurrence of a "physiological" surgery which in each case eliminates GERD pathological disorders without causing side effects)