CASE STUDYHIATAL HERNIA

REVISION

Recurrent Hiatal Hernia Revision with MIROMESH™ Biologic MatrixStudy conducted by Steven J. Binenbaum, MD, FACS, Laparoscopic SurgeonMonmouth Medical Center, Long Branch, New Jersey

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History of Present IllnessIn early 2014, a 37-year-old female presented with complaints of chronic gastroesophageal refl ux, post-prandial nausea and diffi culty swallowing. Patient was initially treated with medications (PPI) but medical treatment only marginally improved her symptoms.

Initial work-up included upper GI series, fl exible 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 fl exible upper endoscopy examinations, which confi rmed 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 HistoryPatient’s past medical history was signifi cant for hypothyroidism, breast cancer and gastroesophageal refl ux. She had no history of abdominal surgery other than the previous hiatal hernia repair. Patient was maintained on Protonix® (pantoprazole sodium) for gastroesophageal refl ux. Physical examination was normal. Patient was 5’7” tall, weighed 190 pounds, and had a BMI of 29.8.

Intra-Operative FindingsDuring the surgery in April of 2015, intra-operative fi ndings were signifi cant for partial herniation of the Nissen fundoplication wrap into the chest (Images 1 and 2).

PATIENT INFORMATION

Image 1. Hiatal hernia pre-procedure, showing Image 2. Recurrent hiatal hernia. previously used mesh.

Case NotesOne 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.

Image 5. MIROMESH was placed over the previous Image 6. Final repair. crural repair.

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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.

ProcedureFundoplication 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 Image 4. Completed repair over the recurrent the abdomen. hiatal hernia.