Biologic Mesh Use in Hiatal Hernia Repair

The diaphragmatic hiatus is a dynamic structure. It contracts and relaxes with every breath you take and dilates with every swallow. Supporting this moving structure is a thin layer of fibrous tissue called the phreno-esophageal membrane, PEM. PEM is an extension of both the endo-thoracic and transversalis fasciae and binds the distal esophagus to the hiatus without impairing motility and function of either structure. PEM is completely dissected during a hiatal hernia repair leaving the distal esophagus “naked” as it crosses the newly formed hiatus.

There is no replacement for PEM once dissected. Fortunately, the fundoplication mechanism of action restores the anti-reflux barrier. Preventing the wrap fundoplication from herniating into the chest improves its anti-reflux barrier function. The most important key to preventing hernia recurrence is proper esophageal mobilization. Proper closure of the hiatus also helps decreasing hiatal hernia recurrence. At Houston Heartburn and reflux Center we routinely use pledgeted sutures to close the hiatus. Soft pledgets prevent sutures from tearing through muscle. In addition, pledgets cause local fibrosis that reinforces the repair.

In certain cases, the crural muscles are weak and atrophic. A biologic mesh like Gore BIO-A or Surgisis is used to reinforce the suture closure. The mesh is secured using a fibrin sealant like Evicel or Tisseel. I rarely suture the mesh to the underlying muscle to avoid injury to mediastinal and chest cavity structures. The use of biologic mesh in hiatal hernia repair is safe and is not associated with increased complications. The hernia recurrence rate however is not decreased when a mesh is added. A recent article by Oelschlager et al published in Surgical Endoscopy showed no difference in the recurrence rate among patients undergoing primary hiatal closure, and closure with mesh reinforcement with or without a relaxing diaphragmatic incision.

The key to improving hiatal hernia repair outcome is clearly early intervention. Living with a large hiatal hernia for many years result in atrophy and lateral retraction of the crura. It also results in esophageal shortening and fibrosis. Biologic mesh, while safe, lack the durability and strength to maintain the hiatal opening closed. We currently do not have a surgical solution to firmly close the hiatus short of using a permanent mesh. Unfortunately, permanent mesh use is contraindicated in hiatal hernia repair as it ends up eroding into the esophagus.

If you or someone you know suffer from GERD or have a hiatal hernia, get evaluated by a reflux specialist. The earlier you are diagnosed and properly treated the better are the outcomes.