Antireflux Surgery – Mesh Augmentation in Hiatal Hernias
The management of hiatal hernias in the context of antireflux surgery through primary hiatoplasty is associated with a recurrence rate of 10 to 20% according to various studies (1, 2, 3, 4, 6, 10, 11, 15, 18, 19, 23), causing the fundoplication to migrate cranially and become intrathoracic, a condition referred to as "slipped-Nissen fundoplication."
As early as 1993, the use of synthetic meshes for the closure of hiatal hernias was investigated (12). With the increasing use of meshes at the hiatus, concerns regarding complications associated with alloplastic reinforcement have been raised more frequently in the past (12, 17, 22). On the other hand, the number of recurrent hernias after mesh reinforcement at the hiatus decreases (5).
The main issues with alloplastic reinforcement at the hiatus are seen as:
1. Increased postoperative dysphagia
The use of meshes at the hiatus leads to an immediate postoperative increase in dysphagia rates compared to mesh-free management, although no difference is found after one year. However, persistent stenoses due to scar formation and fibrosis in the periesophageal tissue are problematic, as they usually cannot be resolved by dilation but require resection (20, 21).
2. Mesh perforation in the esophagus and stomach
Mesh perforation is considered the most dramatic complication of hiatal augmentation, first reported in 1998 (17). It can occur late postoperatively, with cases known after 7 or 9 years. Occasionally, it may be possible to retrieve the foreign body endoscopically, but usually, a partial esophagogastrectomy is indicated.
3. Infection risk
The implantation of a foreign body is always associated with a certain risk of infection. Although the frequency is low at 0.5% of cases (5), it is generally consequential, as it requires surgical revision of the cardia region.
4. Secondary problems
Problems can arise from the method of mesh fixation at the hiatus. Spiral staples should be used with extreme caution, as several cases of pericardial lesions are known. In 2000, a coronary vessel lesion with a fatal outcome was reported (13). As an alternative to the use of staples, fixation with tissue glue or sutures is recommended (16).
Mesh Materials
Regarding the potential complications from the use of synthetic meshes at the hiatus, the trend is towards the use of absorbable mesh materials, which are expected to integrate better into the tissue matrix and result in less fibrosis and adhesion formation. Initial results show fewer stenoses and erosions than with non-absorbable meshes, but an increase in recurrences compared to non-absorbable meshes is noted (5). It is currently unclear to what extent particularly lightweight, non-absorbable meshes, whose design and/or coating is intended to prevent a foreign body reaction, are helpful (5, 7, 8, 9).
In 2010, the Society of American Gastrointestinal and Endoscopic Surgeons, SAGES, published the results of a survey on alloplastic management of hiatal hernias (5). The results for approximately 5,500 hiatal hernias where mesh reinforcement was performed are as follows:
- 77% and 23% of procedures are performed laparoscopically and openly, respectively
- Types of meshes used: 28% biomaterial, 25% PTFE (polytetrafluoroethylene), 21% PP (polypropylene)
- Mesh fixation: 56% suture
- Hernia recurrences: 3% (predominantly absorbable meshes)
- Stenoses and erosions: 0.2% and 0.3% (predominantly non-absorbable meshes)
The study concludes that alloplastic management of hiatal hernias is suitable for significantly reducing the recurrence rate compared to mesh-free management, with an acceptable risk of complications.