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Hiatal hernia is defined as a protrusion of abdominal structures different than the esophagus into the thoracic cavity through a widening in the hiatus. Recurrence following primary hiatal hernia repair is an important problem. The radiological incidence of recurrence is 30-42% while symptomatic recurrence seems to affect 5% of patients. Most patients are elderly and have comorbidities.
Following the principles of tension-free repair with mesh reinforcement in inguinal and ventral hernia repair that are associated with decreased recurrence rates, it is suggested that crural reinforcement will reduce the rates of hiatal hernia recurrence.
Controversies still exist regarding the need for mesh reinforcement of the hiatus and on the type of mesh to be used. This video reviews the literature on this topic.
Types of mesh
The ideal mesh for cruroplasty should provide strength to reduce the risk of recurrent herniation, avoiding erosion and dysphagia. It should be underlined that, compared to mesh repair of inguinal or ventral hernias, hiatal defects have a dynamic nature in which the continual motion provokes an ongoing friction of the mesh at the esophagus and stomach that can result in mesh erosion.
Different materials have been used for hiatal mesh repair:
Also, various mesh shapes have been used:
Suture versus mesh repair
Many studies have shown a decrease in paraesophageal hernia recurrence with the use of mesh repair. A recent meta-analysis (Sathasivam R et al. 2019) demonstrated a significant reduction in recurrent hiatal hernia after mesh repair compared to non-mesh repair (OR 0.48, 95% CI 0.32 – 0.73, p< 0.05). Nonetheless, long term data is inadequate and the studies included are heterogeneous and thus, clear recommendations on the use of mesh repair for hiatal hernias are not possible.
Biological
A prospective study by the Oregon group (Abdelmoaty et al.) showed that after 1 year follow-up after paraesophageal hernia repair with biologic Phasix-ST, the recurrence rate was 8%, with no reoperation, mesh infection or mesh erosion. Other groups have shown a 9% recurrence rate at the expense of a higher than expected complication rate.
Complications of mesh repair
Erosion and migration are the most feared complications encountered after mesh repair. A systematic review yielded a 1.9% rate of mesh-associated complications in the series, reporting at least one mesh-related complication. Reports on biological mesh repair have shown no erosions, strictures or dysphagia after more than 4 years’ follow-up.
Compared to single closure of the hiatus, several studies have described an increased risk of dysphagia in the early postoperative period after hiatal hernia repair with mesh. The dysphagia rate was similar to single closure after 1 year.
A recent systematic review (Li et al. 2019) described 50 cases of mesh erosion reported in the literature. Of these, 50% occurred in the esophagus, 25% in the stomach and 23% in the gastroesophageal junction. There is one report of aorta erosion with early bleeding. 84% of patients complained of dysphagia. Other symptoms were weight loss, epigastric pain, heartburn, regurgitation and bleeding. The interval to mesh erosion diagnosis ranged from 7 days (aorta erosion) to 20 years, but in more than two thirds of patients erosion occurred in the two first years after primary surgery. One third of the patients were treated by minimally invasive procedures (endoscopy, laparoscopy or a combination of both), but half of the patients required open surgery, with 19.6% requiring an esophageal resection and 5.9% total gastrectomy.
Conclusions
There is no clear recommendation on the use of mesh in the hiatus or on its type and shape