OBJECTIVE: Paraesophageal hernias (PEH) are commonly and safely repaired via a laparoscopic approach, usually with a posterior cruroplasty followed by an anti-reflux operation. Unfortunately, there is a relatively high rate of recurrent hiatal herniation reported postoperatively. We sought to determine the effectiveness of the routine use of mesh in laparoscopic repair of PEH.
Methods: A systematic literature search (Medline, Embase, Cochrane Library, and Pub of Med) was performed to identify all eligible articles. Randomized controlled trials (RCT) and prospective cohort studies (PCS) comparing use of mesh (biologic and prosthetic) versus primary suture repair were reviewed and the methodologic quality of included studies was evaluated independently by 2 authors. Pooled estimates of relative risk of recurrences were calculated using a random effects model to account for heterogeneity in study designs.
Results: In total, 216 abstracts were reviewed and assessed for eligibility, with 3 RCT and 3 PCS identified. A total of 455 patients were analyzed. Mesh closure was associated with 60% lower risk of recurrence than primary suture repair (Relative risk (RR)=0.40, 95% CI 0.22 to 0.73, p=0.003). Similar trends were seen when stratified by study design type (for RCT, RR=0.30, 95% CI 0.15 to 0.62, p=.001) but were not statistically significant for cohort studies (RR=0.77, 95% CI 0.26 to 2.34, p=0.60), possibly due to sample size (only 47 patients with mesh closure in PCS) or selection biases inherent in PCS. There were no reports of mesh erosion in any study.
Conclusion: In pooled analysis, the use of mesh seems to offer an advantage over primary suture closure in laparoscopic repair of paraesophageal hernia. Future well designed studies evaluating the clinical implications of use of biologic versus prosthetic mesh are warranted.