Evaluation of acellular human dermis reinforcement of the crural closure in patients with difficult hiatal hernias E. Lee, M. M. Frisella, B. D. Matthews, L. M. Brunt Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, St. Louis, MO, USA Received: 5 August 2006/Accepted: 9 October 2006/Online publication: 8 February 2007 Abstract Background: Biologic prosthetics may circumvent mesh- related complications at the esophageal hiatus by becoming remodeled by native cells. We present our experience with acellular human dermal matrix in the repair of difficult hiatal hernias (HH). Methods: Records of 17 patients who underwent lapa- roscopic HH repair using acellular human dermis to buttress the crural closure were analyzed. Hernias were paraesophageal (PEH) in 12 patients, large type 1 in 1 patient, and recurrent after prior HH repair in 4 patients. Barium swallow (BAS) was obtained 6–12 months after surgery. (Data are presented as mean ± standard deviation.) Results: Mean patient age was 65 ± 12 years and BMI was 31 ± 4. Mean gastroesophageal (GE) junction distance above the diaphragm in the PEHs was 4.9 ± 1.5 cm; 9 of 12 patients with PEH had more than 50% of the stomach in the chest. Mean operating time was 273 ± 48 min. Average hiatal defect size was 4.7 · 2.7 cm, with 4.2 ± 1.2 sutures used to close the crura. Nissen fundoplication was performed in all patients, esophageal lengthening in four patients, and anterior gastropexy in three patients. Mean hospital length of stay (LOS) was 2.3 ± 0.8 days. Mean followup was 14.4 ± 4.4 months. Postoperatively, only one (6%) pa- tient had heartburn/regurgitation, one (6%) had mild dysphagia, and two (12%) take proton pump inhibitors. Followup BAS at 10.3 ± 4.9 months after surgery showed small recurrent hernias in two patients (12%), but only one was symptomatic. In addition, there was one symptomatic failure of a redo Nissen in an obese patient. Reoperative gastric bypass 15 months later showed an intact crural closure with a remodeled but- tress site. Conclusions: Acellular human dermal matrix may be an effective method to buttress the crural closure in patients with large hiatal hernias. Longer followup in larger numbers of patients is needed to assess the validity of this approach. Key words: GORD / GERD (gastroesophageal reflux disease) — Hiatal hernia — Laparoscopy Primary suture repair has been the standard method for closure of the crura during hiatal hernia surgery. This approach may be insufficient in the setting of large or complicated hiatal hernias because the crura may be thin, the fascial tissue is often not strong or may be damaged during the dissection, the repair may be under tension, and the continuous movement of the diaphragm may further stress the closure. As a result, failure rates in patients undergoing laparoscopic paraesophageal hernia (PEH) repair in series in which patients were carefully followed and studied radiographically have ranged from 22% to 42% [1, 9, 15, 20]. Over the last 15 years, tension-free mesh repair of inguinal and incisional hernias has largely replaced primary suture repairs because of improved outcomes and lower failure rates. Because failure of the crural closure is one of the primary reasons for recurrence following hiatal hernia repair, some groups have rec- ommended synthetic prosthetic mesh as a tension-free or buttressed repair of the hiatal closure, with an associ- ated drop in recurrence rate [11, 14, 17, 19]. However, the use of conventional prosthetic materials at the hiatus has not been generally accepted because of concerns of mesh-related complications such as visceral erosion or stricture formation. The potential for mesh-related esophageal compli- cations has led to the consideration of biologic materials to reinforce the hiatal closure [23]. Acellular human dermal matrix is an allogeneic biologic remodelable material that consists of decellularized human cadaveric Presented at the April 28, 2006 SAGES Meeting, Dallas, TX Correspondence to: L. M. Brunt Surg Endosc (2007) 21: 641–645 DOI: 10.1007/s00464-006-9117-4 Ó Springer Science+Business Media, Inc. 2007