Hiatal Hernia Repair with Biologic Mesh Reinforcement Reduces Recurrence Rate in Small Hiatal Hernias

Elizabeth M Schmidt, MD, Jason F Reynoso, MD, Dmitry Oleynikov, MD. University of Nebraska Medical Center

Introduction: The use of biological mesh for crural reinforcement during hiatal herniorrhaphy has been shown to decrease recurrence rates in patients with hiatal hernia greater than 5cm. However, there remains some controversy as to the benefit of crural reinforcement in smaller hernias. Our current practice is to employ the use of absorbable mesh in all hiatal hernia repairs. This study compares the results of those patients in our database with small hiatal hernias (1 to 5 cm) who had absorbable mesh implanted at the hiatus versus those who had suture cruroplasty repair.

Methods: A single-institution retrospective review was performed between 2002 and 2009. All patients with hiatal hernia measuring 1 to 5 cm seen on barium swallow and/or esophagogastroduodenoscopy (EGD) were included in the study. These patients were then evaluated based on surgical repair: one group had crural reinforcement with biologic or synthetic absorbable mesh and the other group had suture cruroplasty only. All patients underwent a standardized hiatal hernia repair with complete excision of the sac, mediastinal dissection to attain 2-3 cm of intrabdominal esophagus, suture cruroplasty with or without U shaped absorbable mesh overlay and gastric fundoplication. The patients were followed with a postoperative symptom questionnaire at 1, 6 and 12 months. All patients had follow up barium swallow and/or EGD at 12 months.

Results: 70 patients with a hiatal hernia measuring 1 to 5cm were identified. 39 patients had a hernia repair with absorbable mesh and 31 patients had hiatal herniorrhaphy with suture cruroplasty only. All patients had at least 12 months of follow up. Recurrence rate at one year was 16% (5/31) in patients who had suture cruroplasty only. Recurrence rate at one year was 0% (0/39) in patients who had crural reinforcement with absorbable mesh, which was a statistically significant difference (p=0.014).

Conclusions: Small hiatal hernias repaired without mesh recur at a significant rate. Suture cruroplasty alone appears to be inadequate for hiatal hernias measuring 1 to 5cm. Crural reinforcement with absorbable mesh significantly reduces hiatal hernia recurrence rate in small hiatal hernias. We recommend that all hiatal hernias, regardless of size, should be repaired with absorbable mesh reinforcement.