A Meta-Analysis of Trials Comparing the Effectiveness of Use of Mesh in Laparoscopic Repair of Paraesophageal Hernias

Katherine G Lamond, MS MD, Miloslawa Stem, MS, Michael A Schweitzer, MD, Kimberley E Steele, MD, Anne O Lidor, MD MPH. Department of Surgery, Johns Hopkins Hospital

OBJECTIVE: Hiatal hernias are commonly and safely repaired via a laparoscopic approach, typically with a posterior cruroplasty followed by an anti-reflux operation. Unfortunately, there is a relatively high rate of recurrent hiatal herniation reported postoperatively. Our objective was to determine a consensus for effective use of mesh in repair of diaphragmatic hernias using meta-analysis methodology.

METHODS: A systematic literature search (Medline, Embase, Cochrane Library, and Pub of Med) was performed to identify all eligible articles. Randomized controlled trials (RCT) and prospective cohort studies (PCS) comparing use of mesh (biologic and prosthetic) versus primary suture repair were reviewed and the methodologic quality of included studies was evaluated independently by 2 authors. Pooled estimates of relative risk of recurrences were calculated using a random effects model to account for heterogeneity in study designs.

RESULTS: In total, 294 abstracts were reviewed and assessed for eligibility, with 3 RCT and 3 PCS identified. A total of 408 patients were analyzed. Mesh closure was not associated with reduced risk of recurrence compared to primary suture repair when stratified by study design type for RCT (Relative Risk (RR)=0.39, 95% CI 0.09 to 1.67, p= 0.205), for PCS (RR=0.77, 95% CI 0.26 to 2.34, p=0.651), and overall (RR = 0.54, 95% CI 0.24 to 1.23, p=0.141). There were no reports of mesh erosion in any study.

CONCLUSION: In pooled analysis, the use of mesh does not seem to offer an advantage over hernia recurrence when compared to primary suture closure in laparoscopic repair of paraesophageal hernia. Our evaluation of multiple studies analyzed a variety of hernia repair techniques, as well as multiple different types of mesh. Further prospective randomized studies are certainly warranted in an effort to discover the most durable repair for hiatal hernia.