P1.033. DAM (Dual Anchored Mesh) Intercrural Technique for Hiatal Hernia Repair: Case Series Aiming to Reduce Complications and Recurrence

Abstract

Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Hiatal hernia repair with mesh reinforcement remains controversial due to recurrence and mesh-related complications. We present a descriptive case series introducing a laparoscopic intrahiatal intercrural mesh placement technique, potentially aimed at reducing complications associated with conventional prosthetic reinforcement while preserving the expected benefit in recurrence reduction. Methods A descriptive retrospective case series was conducted, including patients with GERD and giant hiatal hernia who underwent laparoscopic hiatoplasty with intercrural mesh reinforcement and fundoplication. Preoperative evaluation included upper gastrointestinal endoscopy, esophagogastroduodenal contrast study, and high-resolution esophageal manometry. The surgical technique consisted of laparoscopic hiatal dissection, systematic division of short gastric vessels, reduction of the hernia sac, and posterior cruroplasty reinforced with a bioabsorbable monofilament mesh with anti-adhesive hydrogel barrier. The mesh was longitudinally tailored according to defect size and positioned at the posterior apex of the hiatus, maintaining at least 2 cm distance from the esophagus. The mesh was folded longitudinally onto itself, with the opening facing the abdominal side, and fixed during hiatal closure in a crura-mesh-mesh-crura sequence using barbed monofilament suture. Fundoplication was subsequently performed with intraoperative endoscopic confirmation of adequate hiatal closure. Results A total of 40 patients were included, with equal male and female distribution and a mean age of 57 years. Mean BMI was 27.9 kg/m2. Preoperative manometry showed normal DCI in 90% of patients and normal IRP in all cases. According to the Chicago Classification, subclinical motor alteration was the most frequent pattern (28.6%), followed by preserved and borderline motility. All patients underwent laparoscopic hiatoplasty using the intercrural DAM technique with individualized fundoplication, most commonly Nissen (42.5%) and Toupet (35%). Mean operative time was 170 minutes, with a mean follow-up of 4 years. Fifteen patients (37.5%) had previous antireflux surgery and underwent redo procedures. Despite the complexity of the cohort, postoperative complications were infrequent, including one hiatal hernia recurrence, one pneumothorax requiring pleural drainage, one postoperative dysphagia requiring endoscopic dilation, and one gastric bubble syndrome. Conclusion Laparoscopic hiatal hernia repair with DAM intercrural mesh placement appears to be a feasible and safe alternative for complex or recurrent hiatal hernias, with low rates of postoperative complications and recurrence during follow-up. This novel intrahiatal reinforcement strategy may reduce complications associated with conventional prosthetic placement while preserving hiatal support. Further comparative studies and long-term follow-up are necessary to confirm the durability, reproducibility, and safety of this technique.