Laparoscopic hiatal hernia repair: mesh or no mesh? A narrative review

Introduction

Laparoscopic hiatal hernia repair (LHHR) was first reported by Cuschieri et al. in 1992 (1). and even in early comparisons the laparoscopic approach carried a lower morbidity, less blood loss, and reduced ICU stay (2). In the early 2000s, however, longer-term follow-up revealed a recurrence rate of nearly 50% on routine esophagram, compared to only 15% in an open surgery cohort (3). Adding a mesh reinforcement to the suture cruroplasty was a natural response to the problem of high recurrence rates. Carlson et al. in 1997 described the first randomized control trial of mesh reinforcement in laparoscopic hiatal hernia repair, using a PTFE keyhole mesh and showing good early outcomes in a small cohort (4). Similarly, Zehetner et al. also published a series, 10 years after their first description of a laparoscopic repair, adding mesh reinforcement and frequent Collis gastroplasty, resulting in a decrease in recurrence rates from 50% to 18% on routine esophagram (5).

The addition of mesh to the laparoscopic hernia repair is intuitive: mesh is routinely used in inguinal and ventral hernias, and a tension-free repair is a basic surgical principle. This is even more compelling at the hiatus, where the diaphragm is under constant repetitive stress from the mechanics of breathing. Conversely, the idea of wrapping a permanent foreign body around any part of the foregut is concerning for most surgeons. The most noteable historical example is the silastic Angelchik prosthesis, introduced in 1979 as an anti-reflux option and eventually taken off the market due to high rates of migration, erosion, and dysphagia (6).

While mesh reinforcement in laparoscopic hiatal hernia repair demonstrated early success at reducing recurrence rates, several limitations emerged. First, the clinical relevance of radiographically diagnosed recurrences is unknown. Most such recurrences are asymptomatic, and many mesh trials do not provide data on symptomatic vs. asymptomatic recurrence (7). Second, and more concerning, is the risk of mesh related complications, including erosion, stricture, and dysphagia. The true incidence of such complications is unknown, as many studies provide only short-term data, and limited descriptions of complications (8,9).

Overall, the use of mesh for hiatal hernia repair remains controversial, and practice patterns differ widely. A 2015 survey of European gastrointestinal surgeons showed that 77% of surgeons use mesh selectively, and 15% use mesh routinely in LHHR. Mesh type, configuration, indications, and method of fixation were all highly variable (10). A 2010 survey of SAGES members had similar results, with a high degree of variability in mesh type, fixation, and configuration (11). There are three main questions that determine the utility of mesh for LHHR: (I) Does mesh reduce long-term recurrence rates? (II) Is the reduction in recurrence rates clinically significant? (III) What is the incidence of mesh-related complications?

This paper will review the literature on these three questions to assist surgeons in determining the ideal role for mesh reinforcement during LHHR. Databases searched included MEDLINE (via Ovid: MEDLINE and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Daily and Versions), Embase (via Elsevier), Scopus, Education Abstracts (via EBSCOhost), and ERIC (via ProQuest).

We present the following article in accordance with the Narrative Review reporting checklist (available at http://dx.doi.org/10.21037/vats-21-10).

The impact of mesh on long-term recurrence rates

The initial proposed benefit of mesh at the hiatus is the same as the benefit of mesh in any hernia: a tension-free repair with lower recurrence rates. While published recurrence rates vary, several studies have reported a greater than 50% recurrence after LHRR (12-14). Prophylactic mesh placement has been shown to decrease this rate considerably. Frantzides et al. showed a decrease in recurrence from 22% with suture repair alone, to 0% with PTFE reinforcement after 2.5 years of follow up (15). Oelschlager et al. randomized 108 patients to suture repair or biologic mesh, and at 6 months found a 24% recurrence rate in the suture group compared to a 9% rate in the mesh reinforced group (P=0.04). Granderath et al. randomized 100 patients and found recurrence in 26% of suture-alone and 8% with polypropylene mesh reinforcement at one year (P<0.001) (16).

Unfortunately, the differences in recurrence rates seem to vanish with longer term follow-up. Oelschlager et al. published a follow up study in 2011, showing that the previously seen difference in recurrence disappeared at 5 years (17). Similarly, Jones et al. published a retrospective analysis of 209 patients undergoing mesh reinforced repair. They found a recurrence rate of 16% at 1 year, but by 5 years, recurrence increased to 39%, matching the published rates for non-mesh repair (18). Moreover, while most studies show a lower short-term recurrence, some do not show a difference. Watson et al. randomized 126 patients with >50% intrathoracic stomach in 2015 to suture alone, absorbable mesh, or non-absorbable mesh; they found no significant difference in recurrence rates (19). Oor et al. in 2018 had similar outcomes, with no difference in recurrence between suture and mesh for patients with large (>5 cm) hernias (20).

Two meta-analyses have tried to combine the data from the various randomized trials on mesh placement to reinforce sutures at the hiatus. Stavros et al. in 2012 found only 3 trials and a total of 267 patients that met their inclusion criteria; in pooled data of these three trials the recurrence after primary repair was 24.3% compared to 5.8% after mesh reinforcement (P=0.001). No study had follow-up beyond a year. Memon et al. published a meta-analysis of 4 trials in 2016; while they also found a reduction in overall recurrence rates, they concluded that any recommendations were hindered by several limitations, including: poor methodologic quality, varying definitions of “recurrence,” incomplete data on mesh complications, short follow-up, and incomplete data on symptomatic vs. asymptomatic recurrences. The authors concluded that mesh and suture repair produce “comparable results” (21).

The clinical significance of hiatal hernia recurrence

Importantly, the initial concern with high recurrence rates after laparoscopic hiatal hernia repair emerged from studies that performed routine imaging at a set time after repair. Many of these studies did not include a comparison of symptoms between the groups with and without radiographic recurrence, leading to questions about the clinical relevance of the finding.

Oelschlager et al., who documented that recurrence rates equalized by 5 years of follow-up, is also one of the only groups to investigate symptomatic recurrences. They found that while over 50% of patients had a recurrence on imaging, there was minimal impact on heartburn related quality of life or symptoms. A large recurrence carried a slight increase in heartburn risk, but overall quality of life as measured by the SF36 did not differ between patients with and without recurrence at 5 years follow-up (22). Dallemagne et al. did a retrospective review of 85 patients; while 66% had recurrence on imaging, there was no relationship between radiographic recurrence and quality of life. Two patients (3%) required reoperation, one non-mesh patient for dysphagia and one mesh patient for symptomatic recurrence (12). Hietaniemi et al. performed routine CT after 165 repairs for giant hiatal hernia; while the majority were non-mesh repair, they found a 30% recurrence rate and no correlation between recurrence and health-related quality of life. Only 4% of patients had what they qualified as a “major” recurrence, with a greater than five centimeter hernia on follow up imaging (23). Overall, there is no evidence that radiographic recurrence correlates with need for reoperation, quality of life, or symptoms. The studies differ, however, in the definition of recurrence and the quality of symptom data.

Importantly, the high rate of asymptomatic, radiologically-determined hernias raises the question of how recurrence should be defined. The radiologic definition is itself in debate. Various authors have defined a recurrence as any amount of gastric tissue above the diaphragm (24); others have used 2 cm (25,26) or 3 cm (12) as specific cut-offs for defining a recurrence. Braghetto et al. proposed a classification score combining endoscopic and radiologic findings with postoperative symptoms to define what a symptomatic or “true” recurrence (13).

Mesh-related complications

Finally, the use of mesh requires an evaluation of mesh-related complications. These include inflammation, esophageal stricture, bleeding, and erosion of the mesh into the esophagus (27). Fixation of the mesh also carries risks, including case reports of cardiac tamponade from tack fixation into the diaphragm (28,29). Unfortunately complications related to mesh placement are often not included in the trials, and the follow-up period is likely too short to establish a realistic complication rate. A 2009 case series of 28 patients with mesh complications is the largest publication to date, and includes six patients requiring esophagectomy as a result of erosion or stenosis (30). This series included both synthetic and biologic mesh complications Not all studies include measurements of dysphagia, although Granderath et al. found a higher rate in patients with mesh compared to the suture-alone group (16).

Although mesh placement has not been shown to decrease the need for reoperation, there is concern it may make reoperation more challenging. While a case-control study in 2016 found no increased risk of 30-day major morbidity or mortality with prior hiatal mesh (31), a 2010 retrospective study found mesh placement at the initial operation was associated with a 6.8-fold increased risk of major resection at reoperation (32).

Discussion

Mesh reinforcement is the standard of care for hernia repair in almost any part of the abdomen. At the hiatus, laparoscopic hernia repair is accompanied by high tension, constant repetitive motion, and an extremely high recurrence rate on follow-up imaging. This makes a strong case for the routine placement of mesh. Currently, the exact role of mesh for LHHR, including indications, shape, type, and fixation method are all controversial. This review evaluates the three crucial questions for surgeons deciding on when or if mesh is indicated at the hiatus.

Recurrence rates are decreased in short- and mid-term follow up with mesh in almost all studies. However, in the few studies that follow patients to 5 years, this difference disappears. Additionally, the clinical significance of the radiologic recurrence is debatable. In many studies, recurrence has no relationship to health-related or general quality of life scales, symptom descriptions, or need for reoperation. Because not all studies distinguish between asymptomatic and symptomatic recurrences, it is difficult to know if a correlation would exist in the subset who have a recurrence detected due to symptoms. Finally, the incidence of mesh related complications is unknown. While these complications are in the literature mainly as case reports, they can be very severe, up to and including the need for esophagectomy. The true incidence is unknown, and likely underreported.

More data is needed to overcome significant limitations in the literature, including relatively small sample sizes, varied definitions of “large” hernia, short follow-up, lack of symptom documentation, lack of descriptions of surgeon experience, and varied definitions of recurrence. While LHHR has major advantages over open surgery and remains the operation of choice, it carries a high recurrence rate. Mesh reinforcement does, in most studies, reduce the short-term incidence of radiologic recurrence, but there is little evidence to suggest it reduces the risk of symptomatic recurrence or the need for reoperation. Mesh complications are serious, and their incidence is unknown. While there may be situations where mesh is indicated, including recurrence after primary repair or giant hernia with inability to close the diaphragm, the data does not support routine use of mesh reinforcement for hiatus closure in LHHR.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Rishindra M. Reddy) for the series “Paraesophageal Hiatal Hernia Repairs, Transthoracic, Transabdominal, Laparoscopic, or Robotic, Which Method is Best” published in Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at http://dx.doi.org/10.21037/vats-21-10

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/vats-21-10). The series “Paraesophageal Hiatal Hernia Repairs, Transthoracic, Transabdominal, Laparoscopic, or Robotic, Which Method is Best” was commissioned by the editorial office without any funding or sponsorship. JF received salary support from Blue Cross Blue Shield Michigan/Blue Care Network for my leadership role in the Michigan Bariatric Surgery Collaborative. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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