Mesh at the Hiatus

Crural repair and reduction of hiatal hernia (HH) are paramount to the success of an antireflux surgery. Case series from the early laparoscopic era (i.e., the 1990s) reported an unacceptably high recurrence rate of HHs. In addition, some patients were found to be naturally predisposed to hernia formation, and recurring hernias were thought to be due in part to inherent defects in healing. Simultaneously, the routine use of synthetic mesh in inguinal and ventral hernia repair was gaining widespread acceptance and was found to be both safe and effective.

These findings set the stage for some practitioners to advocate for the use of mesh at the hiatus. Soon thereafter, several case series described experience with various types of synthetic mesh materials and configurations of mesh at the hiatus, and these studies were strengthened by significantly lower recurrence rates in their series. However, these early reports were followed by isolated case reports describing complications related to mesh use, including catastrophic cases that required esophagogastric resections. These disastrous complications were thought to result from the synthetic nature of the mesh materials being used, so bioprosthetic materials were suggested as attractive alternatives to synthetic mesh. A randomized prospective trial described outcomes in patients with and without use of biologic mesh and found a significant decline in recurrence at 6 months’ follow-up when mesh reinforcement was used. A large series of 28 patients undergoing reoperation with either synthetic or biologic mesh at the hiatus was published that demonstrated that both types of mesh were associated with significant mesh-related complications. Since then, others have reported that reoperation after the use of mesh is significantly more challenging than reoperation in patients in whom mesh was not used and that the patients with mesh are at greater risk of needing an esophagogastric resection.

Perhaps the benchmark for HH repair, with or without mesh, is the sizable open transthoracic series by Maziak et al. They achieved a mean follow-up of 94 months in 90 of 94 patients in their cohort who underwent surgical repair of a large paraesophageal hernia (PEH) over a 36-year period. They reported excellent results in 72 of 90 patients (80%), with anatomic recurrence in only two patients, both of whom underwent reoperation. Table 30.1 summarizes the findings of studies on open PEH repair with objective follow-up.

Since the publication of these early laparoscopic reports, advancements in minimally invasive surgery (e.g., improved visualization, better instrumentation, and greater experience) have helped surgeons achieve more extensive mediastinal dissection, better crus closure, and use of Collis gastroplasty. All of these are associated with improved outcomes with primary crus repair of the hiatus, even for larger HHs. The goal of this chapter is to briefly review the advantages and disadvantages of using mesh at the hiatus.