Expert Commentary: Mesh Reinforcement of Hiatal Closure

  • Mohammed Al Mahroos
  • Carmen L Mueller
  • Gerald M. FriedEmail author


Introduction: The principles of PEH repair involve primary closure of the hiatus around the esophagus after complete reduction of the hernia sac. However, this repair is associated with a high failure rate, leading surgeons to consider prosthetic materials to reinforce the hiatal closure. In this chapter, we review the literature comparing outcomes of hiatal mesh reinforcement to simple closure during laparoscopic PEH repair.

Synthetic (Nonabsorbable) Mesh: Synthetic mesh reinforcement seems to reduce at least short-term recurrences of PEH compared to primary closure alone. Multiple RCTs comparing synthetic mesh vs primary closure alone showed no long-term benefit of mesh. A report found use of PTFE for hiatal reinforcement increased case costs by $960+/−70 USD. In addition, the risk of bleeding, stricture, and erosion of mesh into the stomach or esophagus is increased with the use of synthetic mesh during PEH repair.

Absorbable Mesh: Multiple RCTs have compared absorbable synthetic or biologic mesh to simple closure of the hiatus. Most notably, a multicenter RCT by Oelschlager et al. in 2006 compared Surgisis® to simple closure of the diaphragmatic pillars and concluded that hiatal reinforcement with Surgisis® resulted in fewer early recurrences at 6 months. However, on long-term re-evaluation, there was no difference in recurrence rates at 5 years. An important consideration is that biologic meshes have been reported to cost up to $1200 USD per case. Absorbable mesh-related complications are far less common compared to those associated with synthetic nonabsorbable materials. Fibrosis and dysphagia are the most reported sequelae of absorbable mesh.

Summary and Conclusion: Based on published RCTs and meta-analyses, there is insufficient evidence to support routine mesh reinforcement of hiatal closure. There is no evidence that they reduce recurrence long-term recurrence of PEH, and they are associated with increased complications and costs.


Paraesophageal hernia Laparoscopic surgery Mesh Surgery Hiatal hernia Recurrence 


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Copyright information

© SAGES 2019

Authors and Affiliations

  • Mohammed Al Mahroos
    • 1
  • Carmen L Mueller
    • 1
  • Gerald M. Fried
    • 2
    Email author
  1. 1.Department of General SurgeryMcGill UniversityMontrealCanada
  2. 2.Department of SurgeryMcGill University Health CentreMontrealCanada

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