Laparoscopic Antireflux Surgery: Are Old Questions Answered? Mesh Hernioplasty

Abstract

Hiatal hernias are at high risk of recurrence. Mesh reinforcement after primary approximation of the hiatal crura has been advocated to reduce this risk of recurrence, analogous to mesh repair of abdominal wall hernias. However, the results of such repairs have been mixed, at best. In addition, repairs using some type of mesh have led to significant complications, such as erosion and esophageal stricture. At present, there is no consensus as to (1) whether mesh should be used, (2) indications for use, (3) the type of mesh, and (4) in what configuration. This lack of consensus is likely secondary to the notion that recurrence occurs at the site of crural approximation. We have explored the theory that many, if not most, “recurrences” occur in the anterior and left lateral aspects of the hiatus, normally where the mesh is not placed. We theorized that “recurrence” actually represents progression of the hernia, rather than a true recurrence. This has led to our development of a new mesh configuration to enhance the tensile strength of the hiatus and counteract continued stresses from intra-abdominal pressure.

Brazilian Hernia and Abdominal Wall Society Statement on Large Hiatal Hernias Management

“…Prospective and randomized studies in the literature have conflicting results on reducing recurrences using prostheses to reinforce hiatoplasty. A major limitation is that the few randomized studies analyzed different types of meshes, varying in relation to the material (polypropylene, PTFE, biological, absorbable synthetic), shape (U-, C-, rectangular, circumferential), size (1x3 cm, 3x4 cm), fixation methods (points, staples, glues), and application position (anterior or posterior to the esophagus), in addition to having different definitions as to what large hernias would be 11 , 12 , 30 , 40 .…”

“…Recently, absorbable synthetic meshes were introduced, aiming to induce local proliferation of fibroblasts, favoring the formation of a more resistant scar as well as producing a local inflammatory reaction that would cause greater fixation of the esophagus/fundoplication complex in the hiatus region 40 .…”