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Expert Commentary: Mesh Reinforcement of Hiatal Closure

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

Abstract

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.

Keywords

Paraesophageal hernia Laparoscopic surgery Mesh Surgery Hiatal hernia Recurrence 

References

  1. 1.
    Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg. 1992;163(4):425–30.CrossRefGoogle Scholar
  2. 2.
    Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016;211(1):226–38.CrossRefGoogle Scholar
  3. 3.
    Hedblom CA. The selective surgical treatment of diaphragmatic hernia. Ann Surg. 1931;94(4):776–85.CrossRefGoogle Scholar
  4. 4.
    Hedblom CA. Diaphragmatic hernia: a study of three hundred and seventy eight cases in which operation was performed. JAMA. 1925;85:947.CrossRefGoogle Scholar
  5. 5.
    Fusco EM. The repair of hiatus hernia with tantalum mesh. Mil Med. 1960;125:189–90.CrossRefGoogle Scholar
  6. 6.
    Friedman MH, Mackenzie WC. The clinical use of polyvinyl sponge (ivalon) in the repair of oesophageal hiatus hernia. Can J Surg. 1961;4:176–82.PubMedGoogle Scholar
  7. 7.
    Merendino KA, Dillard DH. Permanent fixation by teflon mesh of the size of the esophageal diaphragmatic aperture in hiatus herniplasty; a concept in repair. Am J Surg. 1965;110:416–20.CrossRefGoogle Scholar
  8. 8.
    Le Page PA, et al. Durability of giant hiatus hernia repair in 455 patients over 20 years. Ann R Coll Surg Engl. 2015;97(3):188–93.CrossRefGoogle Scholar
  9. 9.
    Memon MA, et al. Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia: a meta-analysis and systematic review of randomized controlled trials. Ann Surg. 2016;263(2):258–66.CrossRefGoogle Scholar
  10. 10.
    Oelschlager BK, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213(4):461–8.CrossRefGoogle Scholar
  11. 11.
    Koetje JH, et al. Quality of life following repair of large hiatal hernia is improved but not influenced by use of mesh: results from a randomized controlled trial. World J Surg. 2015;39(6):1465–73.CrossRefGoogle Scholar
  12. 12.
    Mattar SG, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc. 2002;16(5):745–9.CrossRefGoogle Scholar
  13. 13.
    Allison PR. Hiatus hernia: (a 20-year retrospective survey). Ann Surg. 1973;178(3):273–6.CrossRefGoogle Scholar
  14. 14.
    Lebenthal A, Waterford SD, Fisichella PM. Treatment and controversies in paraesophageal hernia repair. Front Surg. 2015;2:13.CrossRefGoogle Scholar
  15. 15.
    Smith GS, et al. Symptomatic and radiological follow-up after para-esophageal hernia repair. Dis Esophagus. 2004;17(4):279–84.CrossRefGoogle Scholar
  16. 16.
    Edelman DS. Laparoscopic paraesophageal hernia repair with mesh. Surg Laparosc Endosc. 1995;5(1):32–7.PubMedGoogle Scholar
  17. 17.
    Paul MG, et al. Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc. 1997;11(3):303–7.CrossRefGoogle Scholar
  18. 18.
    Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc. 1997;11(7):769–71.CrossRefGoogle Scholar
  19. 19.
    Watanabe G, et al. Laparoscopic repair of a paraesophageal hiatus hernia without fundoplication. Surg Today. 1997;27(11):1093–6.CrossRefGoogle Scholar
  20. 20.
    Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig Surg. 1999;16(5):407–10.CrossRefGoogle Scholar
  21. 21.
    Granderath FA, et al. Impact of laparoscopic nissen fundoplication with prosthetic hiatal closure on esophageal body motility: results of a prospective randomized trial. Arch Surg. 2006;141(7):625–32.CrossRefGoogle Scholar
  22. 22.
    Frantzides CT, et al. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg. 2002;137(6):649–52.CrossRefGoogle Scholar
  23. 23.
    Arendt T, et al. Dysphagia due to transmural migration of surgical material into the esophagus nine years after Nissen fundoplication. Gastrointest Endosc. 2000;51(5):607–10.CrossRefGoogle Scholar
  24. 24.
    Trus TL, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg. 1997;1(3):221–7. discussion 228CrossRefGoogle Scholar
  25. 25.
    Carlson MA, et al. Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg. 1998;187(3):227–30.CrossRefGoogle Scholar
  26. 26.
    Schauer PR, et al. Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg. 1998;176(6):659–65.CrossRefGoogle Scholar
  27. 27.
    Coluccio G, et al. Dislocation into the cardial lumen of a PTFE prosthesis used in the treatment of voluminous hiatal sliding hernia, a case report. Minerva Chir. 2000;55(5):341–5.PubMedGoogle Scholar
  28. 28.
    van der Peet DL, et al. Laparoscopic treatment of large paraesophageal hernias: both excision of the sac and gastropexy are imperative for adequate surgical treatment. Surg Endosc. 2000;14(11):1015–8.CrossRefGoogle Scholar
  29. 29.
    Rumstadt B, et al. Gastric mesh erosion after hiatoplasty for recurrent paraesophageal hernia. Endoscopy. 2008;40(Suppl 2):E70.CrossRefGoogle Scholar
  30. 30.
    Griffith PS, et al. Rejection of goretex mesh used in prosthetic cruroplasty: a case series. Int J Surg. 2008;6(2):106–9.CrossRefGoogle Scholar
  31. 31.
    Tatum RP, et al. Complications of PTFE mesh at the diaphragmatic hiatus. J Gastrointest Surg. 2008;12(5):953–7.CrossRefGoogle Scholar
  32. 32.
    Stadlhuber RJ, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009;23(6):1219–26.CrossRefGoogle Scholar
  33. 33.
    Huddy JR, et al. Laparoscopic repair of hiatus hernia: does mesh type influence outcome? A meta-analysis and European survey study. Surg Endosc. 2016;30(12):5209–21.CrossRefGoogle Scholar
  34. 34.
    Antonakis F, Kockerling F, Kallinowski F. Functional results after repair of large hiatal hernia by use of a biologic mesh. Front Surg. 2016;3:16.CrossRefGoogle Scholar
  35. 35.
    Oelschlager BK, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006;244(4):481–90.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Watson DI, et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial. Ann Surg. 2015;261(2):282–9.CrossRefGoogle Scholar
  37. 37.
    Jones R, et al. Long-term outcomes of radiologic recurrence after paraesophageal hernia repair with mesh. Surg Endosc. 2015;29(2):425–30.CrossRefGoogle Scholar
  38. 38.
    Alicuben ET, Worrell SG, DeMeester SR. Resorbable biosynthetic mesh for crural reinforcement during hiatal hernia repair. Am Surg. 2014;80(10):1030–3.PubMedGoogle Scholar
  39. 39.
    Chiruvella A, Lomelin D, Oleynikov D. A cost-comparison of mesh usage in laparoscopic paraesophageal hernia repair. In: Sages. Boston: Sages Archives; 2016.Google Scholar
  40. 40.
    Antoniou SA, et al. Lower recurrence rates after mesh-reinforced versus simple hiatal hernia repair: a meta-analysis of randomized trials. Surg Laparosc Endosc Percutan Tech. 2012;22(6):498–502.CrossRefGoogle Scholar
  41. 41.
    Antoniou SA, et al. Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis. Langenbeck's Arch Surg. 2015;400(5):577–83.CrossRefGoogle Scholar
  42. 42.
    Rathore MA, et al. Metaanalysis of recurrence after laparoscopic repair of paraesophageal hernia. JSLS. 2007;11(4):456–60.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Furnee E, Hazebroek E. Mesh in laparoscopic large hiatal hernia repair: a systematic review of the literature. Surg Endosc. 2013;27(11):3998–4008.CrossRefGoogle Scholar
  44. 44.
    Lidor AO, et al. Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia. JAMA Surg. 2015;150(5):424–31.CrossRefGoogle Scholar
  45. 45.
    Targarona EM, et al. Long-term outcome and quality of life after laparoscopic treatment of large paraesophageal hernia. World J Surg. 2013;37(8):1878–82.CrossRefGoogle Scholar
  46. 46.
    Mittal SK, et al. Outcomes after repair of the intrathoracic stomach: objective follow-up of up to 5 years. Surg Endosc. 2011;25(2):556–66.CrossRefGoogle Scholar

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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