1. Paraesophageal Hernia Repair Utilizing Acellular Dermal Matrix University of South Carolina Department of Surgery Randal L. Croshaw, MD, Stephen A. Fann, MD, James M. Nottingham, MD, FACS Introduction: The repair of large (>5-8cm.) hiatal hernias remains a challenging and controversial subject. While the use of prosthetic mesh has been shown to reduce the recurrence of this type of hernia, there are those that are reluctant to use it. The concerns typically cited in opposition to the use of prosthetic mesh are its risks of esophagogastric erosion and its tendency to induce a fibrotic response leading to stricture formation. While data on the use of acellular dermal matrix for this type of repair is sparse it has been shown to incorporate into living tissue and promote less of a fibrotic response. So far no cases of esophagogastric erosion or stricture formation have been reported for the use of this material in hiatal hernia repair. This patient is a 59 year old obese woman, BMI 43, with an extensive surgical history most notable for multiple incisional hernias and bowel resections that began 15 years prior after an exploratory celiotomy with bowel resection for trauma. She presented with symptoms of intractable reflux and a closed loop SBO. She was found to have a large type III paraesophageal hernia and incisional hernia. At the time of her operation she was found to have dense adhesions, what appeared to be a closed enterocutaneous fistula and loss of domain of her abdominal wall. We chose to use AlloDerm in her paraesophageal hernia repair in order to ensure a tension free repair and avoid a mesh infection in a hostile abdomen. Two 4 x 6 inch strips of AlloDerm were used anteriorly and posteriorly to buttress the primary repair of her paraesophageal hernia. References: 1.Landreneau R, Pino M, Santos R. Management of paraesophageal hernias. Surgical Clinics of North America 2005;85(3):411-32. 2. Targarona EM, Bendahan G, Balague C, et al. Mesh in the hiatus: a controversial issue. Arch Surg 2004;139(12):1286-96. 3. Dutta S. Prosthetic esophageal erosion after mesh hiatoplasty in a child, removed by transabdominal endogastric surgery. J Ped Surg 2007;42:252- 56. 4. Morino M, Giaccone C, Pellegrino L, et al. Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome. Surg Endosc 2006;20(7): 1011-6. 5. Frantzides C, Madan A, Carlson M, et al. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg 2002;137(6):649-52. 6. Champion J, Rock D. Laparoscopic mesh cruroplasty for large paraesophageal hernias. Surg Endosc 2003;17(4):551-53. Attenuation of the crura is typical of large paraesophageal hernias which precludes tension-free primary repair. Outcome: Ten month follow up has revealed no recurrence of her hernia, with only a transient dysphagia that resolved by 8 weeks. Discussion: Large paraesophageal hernias require special considerations in their management. The guiding principle of all hernia operations is to achieve a tension free repair. The esophageal hiatus is no exception. Mesh repair is becoming more accepted as favorable data is slowly accumulating. The advantages of mesh repair with either open or laparoscopic approaches is its reduced rate of recurrence compared to primary repair alone. The rate of recurrence for primary repair ranges from 22-77% while the recurrence rate for mesh repair is 0-35%. Opponents of the use of mesh cite the potential for esophagogastric erosion as its main detractor. Recent studies have reported mesh related complications to be less than 2% which is comparable to primary repair. One report of prosthetic erosion with e PTFE since the year 2000 was found. There have been no reported cases of erosion with acellular dermal matrix. CXR revealing no recurrence while esophagogram reveals an intact GE junction and intraabdominal stomach.