I read with great interest the recent publication in JAMA surgery (Journal of the American Medical Association) titled “Hiatal Hernia Repair with Tension-Free Mesh or Crural Sutures Alone in Anti-reflux Surgery”. This is a double blinded randomized clinical trial with a 13 year follow up. The study was performed in a single center in Sweden. A total of 159 acid reflux patients were recruited and follow-up data obtained from 103 patients (71% response rate, 53 patients had hiatal hernia repair with an absorbable mesh reinforcement, and 50 patients had hiatal hernia repair with no mesh placement). The primary outcome was recurrent hiatal hernia after more than 10 years. Secondary outcomes included difficulty swallowing, PPI consumption, and reoperation rates.
The authors find that reinforcement with nonabsorbable mesh in acid reflux patients with hiatal hernia undergoing anti-reflux surgery for treatment of GERD does not reduce the risk of hiatal hernia recurrence 13 years postoperatively. Hiatal hernia recurrence rates at 13 years were 38% for mesh and 31% for sutures alone. This difference was not statistically significant. However, dysphagia scores for solid food were slightly higher in the mesh group. The authors conclude that routine use of tension-free mesh closure in laparoscopic hiatal hernia repair for GERD is not supported by this study.
At Houston Heartburn and Reflux Center we do not routinely use mesh reinforcement for tension free hiatal hernia repair. We always use pledgeted sutures to close the hiatal hernia posterior to esophagus under no tension. We make sure our hiatal closure is not too tight to avoid narrowing the hiatal opening to prevent post-operative dysphagia. Our dysphagia rate after hiatal hernia repair (with or without mesh) and Nissen fundoplication is zero. We reinforce the repair with absorbable mesh when we notice weakness, attenuation and loss of tone and muscle mass in the right crus compared to left crus. Right and left crura are two muscular bands on either side of the hiatal hernia that anchors the breathing muscle to the vertebral column. In GERD patients, right crus is particularly weakened by acid reflux compared to left crus. The mesh we use is U- shaped and we make sure mesh does not get in contact with esophagus. The purpose of mesh reinforcement is to increase scar tissue formation to strengthen the hiatal closure potentially leading to decreased recurrence rate. Excessive scar tissue, however, may alter lower esophagus wall compliance and pressure leading to difficulty swallowing. We avoid this problem by keeping at least 5 mm gap between edge of mesh and esophagus. We also fixate the mesh in place using biologic glue thus preventing potential mesh displacement and impingement on esophagus.
In summary, we do not advocate the routine use of mesh for hiatal hernia repair. A biologic mesh does not add strength and durability to a hiatal hernia repair if the diaphragmatic crura are strong enough to hold pledgeted sutures. However, when the right crus is “paper thin” we recommend mesh reinforcement. Furthermore, the gastro-esophageal junction, GEJ, is a dynamic area that is constantly contracting and relaxing. Foreign body induced scar tissue formation around the GEJ may result in difficulty swallowing. This has been the case with every foreign body placed in this area including LINX™ which consists of movable magnetic beads. For this reason, we do not encircle esophagus with mesh, we make sure mesh is not placed in direct contact with esophagus, and we only use absorbable mesh. Absorbable mesh dissolves in 3 months after placement. If difficulty swallowing develops (an unlikely event) after we place a biologic mesh, endoscopic balloon dilation is quite effective at breaking down scar tissue around GEJ and alleviating symptoms.
Finally, we strongly recommend, at Houston Heartburn and Reflux Center, early surgical intervention in GERD patients. Right crus muscle weakens, and esophagus shortens as GERD progresses. The longer you wait before surgery, the more tissue damage you sustain potentially leading to higher risk of hiatal hernia recurrence.
Early hiatal hernia with Nissen fundoplication, by a competent acid reflux specialist, is the best approach to avoid hiatal hernia recurrence.