Resolving large hiatal defects still remains a challenge. The primary retroesophageal suture of the diaphragmatic pillars has remained the mainstay of practice for many years [11,15]. Even though there is no consensus, many authors believe that in the cases of large hiatal defects, a structurally altered crura and/or absence of peritoneal lining, a crural reinforcement should be performed [3,4].
Several options have been proposed; amongst them the use of mesh reinforced hiatoplasty. The mesh reinforced hiatoplasty could be performed as an on-lay repair or interposition repair using different types of synthetic mesh i.e. polypropylene, polyester, polytetrafluoroethylen (PTFE) or the combination more suitable for intraperitoneal use . The disadvantages of mesh reinforced hiatoplasty include a possibility of serious complications and also increased costs especially in the usage of PTFE or composite types . The most novel biologic and biosynthetic meshes cause fewer complications [17-19]. However, they adhere less than synthetic ones with a possibility of mesh migration. In addition, they are more expensive than synthetic and have all issues regarding the transfer of heterologous tissue .
Recently, a group from Pecs (Hungary) has offered a biologic alternative by performing fascia lata graft hiatoplasty on the animal model . After macroscopic and microscopic evaluation of fascia lata patches following a 6-month follow-up period there were no signs of inflammation, abscess or extensive scar tissue formation. All fascia lata patches were organized and incorporated in scar tissue increasing tissue strength. Also, the shrinkage was up to 20% (only on sides), the neovascularization arriving from diaphragmal blood vessels and peritoneal integration was observed .
The first use of the autologous fascia lata graft in the treatment of post-traumatic diaphragmatic hernia was published by Janes in 1931 . In 1968, Brain et al. published the use of the autologous fascia lata graft to create a new phrenoesophageal ligament in the transthoracic repair of hiatal hernia . Autologous fascia lata graft has been used in thoracic surgery for reinforcement of stapled lung resection with excellent results .
Encouraged by these results, at our Department we performed 10 laparoscopic autologous fascia lata graft hiatal reinforcements in patients with giant PEHs and a large hiatal defect with the friable crura. The procedure of harvesting autologous fascia lata graft is not technically demanding. It is expected that the main disadvantage of this surgical procedure is cosmetic and includes a scar on the thigh. In addition, the procedure could cause postoperative pain. However, in one case (with no subcutaneous drainage) a mild hematoma occurred but successfully resolved spontaneously. We are not sure whether the discomfort in that specific case was related to the hematoma or procedure itself. No lower limb malfunctioning was observed. It has to be kept in mind that the average age of the patients in our series was 64.2 years. Thus, we could not speculate about the functional result in younger and more active patients. Nevertheless, the average age in this small series does not differ significantly from the average age in the series of 65 giant PEH repairs we performed recently. Indeed, the average age of patients with a giant PEH treated in other series is even higher .
Regarding hiatal hernia features, in our series all patients had the giant PEH with at least 1/3 of the stomach positioned intrathoracically . Five patients presented with chronic gastric volvulus. The average HSA in our series was 10.6 cm2. After performing primary suture of the pillars by using 0 non-absorbable interrupted sutures we placed 10x8 cm the autologous fascia lata graft in on-lay fashion. The patches of autologous fascia lata should be placed in on-lay fashion after cruroraphy, because the tension strength of the graft, to our opinion, is not sufficient for interposition repair. For the graft fixation we used biodegradable tacks. Based on the animal model, if the initial fixation is good, there is no danger of patch migration after complete scar tissue organization .
Except for a mild hematoma that resolved spontaneously, there were no procedure- related complications and the 30 days mortality rate was zero. The average hospital stay of 6.5 days was related to the more detailed monitoring of the patients with new surgical technique, and could be reduced significantly.
Out of 10 patients, 5 completed the annual follow-up visit, while 8 completed 6 months follow-up visit. So far there are no radiologic and symptomatic recurrences (including the problems with swallowing function). However, one patient feels a mild discomfort in the harvested region, which does not influence normal daily activities.