Introduction

Mesh has been increasingly used in hiatal hernia repair. This is still a controversial topic and the use of mesh in hiatal hernia surgery needs to answer the following questions:
What is the hiatal hernia recurrence rate with and without mesh hiatoplasty?
Does mesh affect GERD related outcome?
Are patients with recurrent hernia symptomatic and how many require reoperation?
What is the morbidity of reoperation?

Hiatal Hernia Recurrence with usage of mesh

Various studies have demonstrated lower recurrence with the use of mesh at the hiatus. A randomized study using suture crural closure vs reinforcement with a piece of 1×3 cm of polypropylene mesh demonstrated a recurrence rate of 26% vs 8% (p=0.001) at 1 year.¹ The use of mesh in addition to sutures does not significantly change the recurrence rate compared with the use of mesh alone, though both have significantly reduced rates compared with suture alone.² In a study using PTFE vs suture repair, on median follow-up of 56 months, recurrences in the mesh group were noted early in the postoperative period, whereas recurrence in the suture group continued without plateauing during the follow-up period.³ In addition to synthetic mesh, biologic mesh has also been shown to decrease recurrence rates in a randomized study comparing SIS vs suture repair with a 24% vs 9% recurrence rate.⁴

Does mesh affect GERD related outcome?

Rates of dyphagia appear to be increased early in the postoperative period, but are comparable to the non mesh group when followed out to 1 year.¹ Even with biologic mesh usage, higher rates of post operative dysphagia are noted at 6 months compared with simple suture closure.⁴

Are patients with recurrent hernia symptomatic and how many require reoperation?

Recurrence rates following hiatal hernia surgery are difficult to estimate, with the highest rates (7-43%) being noted where radiologic follow-up is used. Symptoms in these patients range from 34-100%. SF-36 demonstrate lower quality of life scores in asymptomatic radiologic recurrences. ⁴ Reoperation rates though are low (1.7-4.2%) and are significantly higher (9.1% vs 2.3%) when mesh was used in the previous hernia repair.

What is the morbidity of reoperation?

A case series of complications in 28 patients following mesh reinforcement described mesh erosion, dense fibrosis, and esophageal stenosis in patients with previous PTFE, polypropylene and even biologic mesh. 32% of these patients required esophageal resection.⁵ On reoperation, patients with previous hiatal mesh had higher operative time, more blood loss, and increased need for esophageal resection compared with patients without previous hiatal mesh.⁶

References

1. Laparoscopic Nissen Fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation. Preliminary Results of a Prospective Randomized Functional and Clinical study. Granderoth FA, Schweiger UM, Kamolz T, Asche KU, Pointner R. Arch Surg 2005
2. Long-term results of hiatal hernia mesh repair and antireflux laparoscopic surgery. Soricelli E, Basso N, Genco A, Cipriano M. Surg Endosc 2009
3. Objective Follow-up after Laparoscopic Repair of Large Type III Hiatal Hernia. Assessment of Safety and Durability. Zaninotto G, Portale G, Costantini M, Fiamingo P, Rampado S, Giuroli E, Nicoletti L, Ancona E. World J Surg, 2007.
4. Biologic Prosthesis Reduces Recurrence after Laparoscopic Paraesophageal Hernia Repair, A multicenter, prospective, randomized trial. Oelschlager B, Pellegrini C, Hunter J, Soper N, Brunt M, Sheppard B, Jobe B, Pollisar N, Mitsumori L, Nelson J, Swanstrom L. Ann Surg, 2006.
5. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Stadlhuber R, Sherif A, Mittal S, Fitzgibbbons R, Brunt M, Hunter J, DeMeester T, Swanstrom L, Smith CD, Fillipi C. Surg Endosc, 2009.
6. Hiatal mesh is associate with major resection at revisional operation. Parker M, Bray J, Harris A, Belli E, Pfluke J, Preissler S, Asburn H, Smith CD, Bowers SP. Presented at SAGES 2010.
7. Biological Mesh for Paraesophageal Hernia Repair – Pros & Cons. Steven .P. Bowers, M.D. Challenging Hernias Post-Graduate Course. 12th World Congress of Endoscopic Surgery. April 15, 2010