To mesh or not to mesh for hiatal hernias: what does the evidence say

This review article discusses the history and evidence for outcomes from synthetic, biologic, and absorbable synthetic mesh reinforcement of the hiatus during paraesophageal hernia repair. Topics of discussion also include the use of mesh for the repair of type I hiatal hernias, as well as the use of relaxing incisions to close the difficult hiatus. The available literature suggests that use of synthetic mesh may reduce recurrence rates compared to primary closure alone. However, synthetic mesh placed at the hiatus has also been associated with complications that can be highly morbid, even resulting in a gastrectomy or esophagectomy. In contrast, the absorbability of biologic mesh is thought to minimize complications related to the presence of a permanent foreign body at the hiatus. There is evidence that hiatal reinforcement with biologic mesh reduces short-term recurrence rates after paraesophageal hernia repair compared to primary repair alone, but the rate reduction does not persist over long-term follow-up. While absorbable synthetic mesh remains another option, there is limited evidence on whether it effectively reduces recurrence rates after hiatal hernia repair. Due to the lack of high-quality comparative data between different types of mesh for paraesophageal hernia repairs, there is little evidence to guide whether to reinforce the hiatus with synthetic, biologic, or absorbable synthetic mesh.