Download Recurrent Hiatal Hernia Revision with

CASE STUDY
HIATAL HERNIA
REVISION
Recurrent Hiatal Hernia Revision with MIROMESH™
Biologic Matrix
Study conducted by Steven J. Binenbaum, MD, FACS, Laparoscopic Surgeon
Monmouth Medical Center, Long Branch, New Jersey
PATIENT INFORMATION
History of Present Illness
In early 2014, a 37-year-old female presented with complaints of chronic gastroesophageal reflux,
post-prandial nausea and difficulty swallowing. Patient was initially treated with medications (PPI) but
medical treatment only marginally improved her symptoms.
Initial work-up included upper GI series, flexible upper endoscopy and esophageal manometry. Patient
underwent laparoscopic repair of a hiatal hernia with Nissen fundoplication. Diaphragmatic hiatus was
repaired with interrupted Ethibond Excel® sutures (Ethicon), and the repair was reinforced with an onlay
FlexHD® dermis biograft (Ethicon).
Her postoperative course was uneventful until one year later when the patient presented with acute
onset complaints of abdominal/epigastric pain and discomfort. The workup consisted of upper GI series
and flexible upper endoscopy examinations, which confirmed partial re-herniation of the stomach into
the chest. The decision was made to take the patient back to the operating room for the repair of the
recurrent hiatal hernia.
Past Medical History
Patient’s past medical history was significant for hypothyroidism, breast cancer and gastroesophageal
reflux. She had no history of abdominal surgery other than the previous hiatal hernia repair. Patient was
maintained on Protonix® (pantoprazole sodium) for gastroesophageal reflux. Physical examination was
normal. Patient was 5’7” tall, weighed 190 pounds, and had a BMI of 29.8.
Intra-Operative Findings
During the surgery in April of 2015, intra-operative findings were significant for partial herniation of the
Nissen fundoplication wrap into the chest (Images 1 and 2).
Image 1. Hiatal hernia pre-procedure, showing
previously used mesh.
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Image 2. Recurrent hiatal hernia.
Procedure
Fundoplication wrap was intact and was reduced into the abdomen. Periesophageal and perigastric
adhesions were completely divided (Image 3). Additional diaphragmatic crural sutures (0 Ethibond) were
placed to reduce the size of the diaphragmatic hiatus (Image 4). Previously placed FlexHD biograft was
partially excised; however, some areas were well integrated into the crural muscle fibers.
A 6X8 cm MIROMESH Biologic Matrix (Miromatrix) was placed over the previous crural repair (Images 5
and 6). To secure the MIROMESH in place, an Evicel® fibrin sealant (Ethicon) was first sprayed over the
crural repair followed by placing the MIROMESH as an onlay. Evicel fibrin sealant was again applied over
the entire surface of the mesh. Using fibrin glue is safe and allows the mesh to adhere well to the crura.
Image 3. The hernia was resected and reduced into
the abdomen.
Image 4. Completed repair over the recurrent
hiatal hernia.
Image 5. MIROMESH was placed over the previous
crural repair.
Image 6. Final repair.
Case Notes
One month post procedure, the patient’s symptoms resolved. Repeat upper GI series and endoscopy
examinations were normal without any evidence of hernia recurrence.
The MIROMESH™ Biologic Matrix, the latest mesh available for hernia repair, is easy to suture and easy to
use. While the use of a product made from highly vascularized porcine liver is a promising alternative for
hernia repair, formal clinical data that detail associated recurrence rates are needed.
INTENDED USE: The Miromatrix Biologic Mesh is intended to be implanted to reinforce soft tissue.
The physician’s views represented in this case study do not necessarily represent the views of Miromatrix Medical Inc.
[email protected]
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SM-029 REV. A ©2015 Miromatrix Medical Inc.
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