Change of Technique: With or Without Mesh?

Abstract

Despite increasing experience with laparoscopic sliding or para-oesophageal hernia repair, authors are continuing to report recurrence rates between 30 and 40% with simple primary suture repair of the hiatus [1]–[3]. This high recurrence rate is also documented for the open approach in long-term follow-up series [4]. As there is a paradigm shift in the repair of inguinal and ventral hernias, discussion arises also for the hiatus, whether to close it by simple suture technique, tension-free, or by the use of meshes. The experience during the past 10 years suggests that the most important technical steps for maintaining the stomach in place in the abdomen are visceral reduction and sac excision, fundoplication and crural closure [5]. Whereas there is wide agreement concerning sac excision and fundoplication, controversy exists about the technique to close the crura. There are no exact data available as to why hiatal hernias recur. The tension on the crura, the diameter of the hiatus, the anatomy of the pillars and the intra-abdominal pressure of the patient are suggested as the main reasons for the failure of hiatal repair. As simple sutures seem to be unable to restore the hiatal anatomy for a long time and cannot provide a tension-free repair, attention is being paid by a few surgeons to the use of prosthetic material for repair or re-inforcement of the hiatus.