Autologous Posterior Rectus Sheath as a Vascularized Onlay Flap: a Novel Approach to Hiatal Hernia Repair

Despite the use of various prosthetic materials and advances in suturing techniques by high volume esophageal surgeons in specialized centers, the long-term success of hiatal hernia repair in older patients with large hiatal defects remains a challenge. Hiatal hernia surgery violates one of the major tenants of hernia surgery given that it involves approximating muscle, not fascia, and often does not result in a tension free repair. It may be for this reason that primary laparoscopic repair continues to carry unacceptable long-term recurrence rates of up to 50%.^1,2 The need to reinforce the hiatus with durable material to counteract any resultant tension has taken two primary forms: reinforcement with permanent mesh or reinforcement with biologic mesh. Both of these approaches have resulted in suboptimal long-term results compared to simple primary suture repair.^3,4 Furthermore, permanent mesh carries an unacceptable risk profile of shrinkage with erosion into the esophageal lumen, dense fibrosis, and esophageal stenosis which can lead to disabling dysphagia.^5‐7 Biologic mesh avoids many of these complications but does not appear to serve any benefit for long-term recurrence rates and is clinically equivalent to primary repair without mesh with added costs.^8‐10 Finally, reoperative surgery in patients in whom prosthetic material has been placed or in whom prosthetic material still remains fraught with major complications and is often avoided despite patients suffering large recurrences associated with disabling symptoms.

Here we describe a novel use of an autologous vascularized posterior rectus sheath fascia onlay to reinforce hiatal hernia repair via the robotic approach. As recently described for complex abdominal closure following liver transplant, we employed similar principles of harvesting a posterior rectus sheath flap¹¹ that remained vascularized via the falciform ligament of the liver that we verified by indocyanine green (ICG) injection and imaging. The vascularized segment of the right posterior rectus sheath is rotated to the diaphragmatic hiatus after suture approximation of the hernia defect, circumferentially fashioned around the esophagus and sutured to the diaphragm. A major advantage of this approach is the use of an autologous high integrity and thick tissue including the peritoneum that remains vascularized and properly orientated such that the peritoneum is facing the stomach. The herein described approach during robotic surgery is straightforward and simple and offers the advantage that the vascularity of the transposed flap can be confirmed with ICG, the peritoneum is facing the stomach possible lessening the effect of scarring and adhesions, and the muscle side of the graft faces the diaphragm. The patients’ characteristics are described here:

Patient 1 is a 69-year-old man with chronic large paraesophageal hernia with mixed type gastric volvulus (Fig. 1a) which was increasingly symptomatic. He had no previous surgery and was otherwise in good health with no significant co-morbidities. His hiatal hernia had been known to be present for over 10 years during which he contemplated surgery based on intermittent episodes of partial obstruction. Patient is now 5 months postoperatively from the described technique and asymptomatic with no further episodes of pain, vomiting, obstruction, or dysphagia.

Patient 2 is a 72-year-old woman with a recurrent paraesophageal hernia. She had her initial laparoscopic repair with biologic mesh and a partial (270°) posterior fundoplication approximately 18 months prior which failed 3 months after surgery based on recurrent symptoms of abdominal pain, GERD symptoms, and imaging showing a recurrent hernia (Fig. 1b). We hypothesize this recurrence was multifactorial but likely due to patient’s age, size of the original defect, attenuated tissues, and tension. The patient is now 5 months postoperatively from the described technique and asymptomatic with no further episodes of pain or GERD.

Robotic hiatal hernia repair has been described by others^12‐14 and is carried out in standard fashion with total sac excision, intra-abdominal mobilization of the distal esophagus, suture repair of the hiatal defect by approximating the crura, and performance of an anti-reflux fundoplication. Once this is carried out and completed, harvest of the right posterior rectus sheath with its blood supply is achieved via preservation of the falciform ligament of the liver. First, the laparoscope angle is changed to 30° up. The only deviation from the original reports of robotic hiatal hernia repair is that ports are placed well below the umbilicus to allow for access to the intended right posterior rectus sheath flap (Fig. 2). Additionally the Nathanson liver retractor is placed far left of midline to avoid disruption of the falciform ligament and the vascular pedicle.

The dissection proceeds using the robotic scissors with cautery function and begins laterally at the site at which the lateral line of the rectus fascia/muscle is visualized. A posterior rectus sheath segment of approximately 12 cm in the longitudinal axis and 8 cm in the horizontal axis is envisioned to be harvested while remaining attached to the falciform and round ligaments. Cautery marks can be used to map out the projected tissue harvest. Beginning laterally (longitudinally) and caudally (horizontally), a plane is developed until which time the rectus muscle is visualized indicating that the proper plane has been entered. This incision is extended laterally to the lateral edge of the rectus muscle and medially just lateral to the linea alba (Fig. 3).

During this dissection, it is important to preserve the integrity of the linea alba but with careful preservation of the round ligament and its associated vessels which maintain the vascularity of the flap. This dissection of the posterior sheath is then carried cephalad toward the falciform ligament. Upon approaching the falciform ligament, the cephalad edge/border of the flap is designated by opening the avascular portion of the falciform ligament, while preserving the draining vessels through the falciform. The dissection of posterior sheath is then completed, with the sheath free from the muscle and solely attached by the falciform ligament. Once the graft/flap is fully mobilized and attached only by the falciform ligament (Fig. 4), the indocyanine green (ICG) 5 mg dose is injected, and the vascularity examined (see technique video).

The flap is then rotated under the liver allowing the falciform ligament to fall within the sagittal fissure. The flap is brought under the left lobe of the liver without twisting of the pedicle towards the hiatus (Fig. 5a) making sure that the peritoneum is facing the stomach. At this point, a keyhole-like incision can be made at the surgeon’s discretion to allow the graft to encircle the esophagus. NOTE: the posterior sheath flap, in contrast to prosthetic material, can be placed snug against the esophagus given that it is autologous vascularized tissue with a low potential to fibrous and constrict the esophagus. Keeping the peritonealized side of the flap intra-abdominal, the sheath is attached to the diaphragmatic hiatus with as many sutures as needed to affix it against the defect and diaphragm such that it appears flat and partially stretched along the diaphragmatic muscle while avoiding key vascular structures on both the right (vena cava) and left (right ventricle) sides (Fig. 5b).

Technique video link: https://​www.​dropbox.​com/​s/​v5jjobub76662av/​Posterior%20​rectus%20​sheath%20​PEH%20​repair%20​Vigneswaran.​mov?​dl=​0

Large paraesophageal hernia repairs and recurrent hiatal hernia repairs can be challenging given patient-related factors, the complex nature of the hernia defects, and the technical challenge of operating in a previously operated site. Although the long-term results of this procedure remains to be established, including its durability and safety, the report herein described suggests that this novel approach is a promising technique and is based on strong physiologic rationale.