Management of the Crura During Laparoscopic Sleeve Gastrectomy

Despite the increasing number of bariatric procedures being performed, the optimal strategy for managing the crura during laparoscopic sleeve gastrectomy (LSG) remains controversial. Options include no closure, primary suture closure, and suture closure with mesh reinforcement. We sought to investigate outcomes associated with each technique and determine if any approach proved to be superior. Methods This is a retrospective cohort study that evaluated patients undergoing LSG performed by a single surgeon in a 7-year period. Data were collected via chart review. The primary endpoint was hiatal hernia presence at 5 years post-operatively. Secondary endpoints included post-procedural complications (nausea, vomiting, dysphagia, or reflux) at 30 days post-operatively. Results A total of 361 patients were included in the analysis: 154 without crural closure, 164 primary crural closure, and 43 primary crural closure with mesh reinforcement. Rates of hiatal hernia occurrence at 5 years were 9.7% (no closure), 14.0% (primary closure), and 16.3% (closure with mesh reinforcement), respectively, and did not differ significantly among the 3 cohorts (P = .37). Overall rates of 30-day complications were 11.5%, 21.5%, and 28.6%, respectively ( P = .015). Conclusion Rates of hiatal hernia after sleeve gastrectomy do not differ, regardless of management of the crura. In addition, and perhaps more significantly, avoidance of crural closure was associated with fewer 30-day complications. In fact, the highest rate of 30-day complications was seen in the group that received closure with mesh reinforcement. These data suggest that crural closure during LSG should be avoided. Further prospective study of these findings is warranted.