Antireflux surgery - mesh augmentation in hiatal hernias
The management of hiatal hernias in the setting of antireflux surgery by primary hiatoplasty is associated with a recurrent hernia rate of 10% to 20%, depending on the study [1,2,3,4,6,10,11,15,18,19,23], causing the fundus cuff to migrate craniad and reside within the chest, which is referred to as "slipped Nissen fundoplication."
The use of plastic mesh in hiatal hernia repair was first explored as early as 1993.[12] However, in the past the increasing use of mesh at the hiatus has raised concerns about alloplastic buttressing in light of the complications that have been observed.[12,17,22] On the other hand, the incidence of recurrent hernias decreases after hiatal mesh augmentation.[5]
The main problems seen with alloplastic reinforcement at the hiatus include:
1. Rise in postoperative dysphagia
The use of mesh at the hiatus increases the rate of dysphagia in the immediate postoperative period compared with management without mesh, but after one year the outcomes do not differ. However, persistent stenosis due to scarring and fibrosis in the peri-esophageal tissue is a problem, as it usually cannot be resolved by bougienage but requires resection.[20,21]
2. Mesh perforation into the esophagus and stomach
Mesh perforation, first reported in 1998, is considered the most dramatic complication of hiatal augmentation.[17] It may arise very late after surgery; cases after 7 or 9 years have been reported. Sometimes, retrieval of the foreign body by endoscopy may be successful, but most cases require partial esophagogastrectomy.
3. Risk of infection
The implantation of a foreign body is always associated with a certain risk of infection. With 0.5% of cases [5], the incidence is low but generally serious in consequence, requiring surgical revision of the cardiac region.
4. Secondary problems
Problems can arise due to the way the mesh is fixed to the hiatus. Helical tacks should be used with great caution, as several cases of pericardial lesions have already been reported. In 2000, one case of coronary vascular injury with fatal outcome was reported.[13] One recommended alternative to the use of tacks is fixation by fibrin sealant or suture.[16]
Mesh material
Regarding the potential complications from the use of alloplastic mesh at the hiatus, the trend is toward the use of absorbable mesh materials, which are expected to better blend into the tissue matrix and reduce fibrosis and adhesion formation. Initial results demonstrate fewer stenoses and erosions, but suggest an increase in the recurrence rate, compared with nonabsorbable meshes.[5] At present, the extent to which nonabsorbable lightweight meshes whose mesh design and/or coating are intended to prevent foreign body reaction, are helpful remains unclear.[5, 7, 8, 9]
In 2010, the Society of American Gastrointestinal and Endoscopic Surgeons, SAGES, published the results of a survey on hiatal hernia repair with alloplastic mesh.[5] The outcomes on some 5,500 hiatal hernias augmented with mesh are as follows:
§ 77% of procedures were performed laparoscopically and 23% by open surgery
§ Types of mesh used: 28% biomaterial, 25% PTFE (polytetrafluoroethylene), 21% PP (polypropylene)
§ Mesh fixation: 56 % suture
§ Recurrent hernia: 3% ( mostly absorbable mesh)
§ Stenoses and erosions: 0.2% and 0.3% respectively (mostly non-absorbable meshes)
The authors concluded that hiatal hernia repair with alloplastic mesh can significantly reduce the recurrence rate of hiatal hernias, and with acceptable risk of complications, compared to hiatal hernia repair without mesh.