Comment on “Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials” : Annals of Surgery Open

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Letter to the Editor

Comment on “Sutured Versus Mesh-augmented Hiatus Hernia Repair: A Systematic Review and Meta-analysis of Randomized Controlled Trials”

Hung, Chao-Ming MD*,†; Lee, Po-Huang PhD†,‡; Lu, Kang PhD§,‖; Chiu, Chong-Chi MD*,‖,¶

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doi: 10.1097/AS9.0000000000000173
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To the Editor,

We read with great interest a recently published article comparing tension-free mesh with suture-alone cruroplasty in hiatus hernia repair surgery by Petric et al1. The incidence of radiological recurrent hiatus hernia after laparoscopic repair surgery ranged between 11% and 67%.2 This disparity might be caused by different patients’ conditions (preoperative hiatus size, and crural muscle fiber weakness), various surgical techniques (degree of esophagus mobilization, hernia sac retention or not, different tension on the crural repair, and different types of mesh used, or not), inappropriate tension to the diaphragm caused by long-term exertion, non-consensus endoscopic, radiologic, and symptomatic definitions during follow-up. However, reported recurrence rates are based on the interpretation used with different study series precluding recurrent hiatus smaller than 2 cm.3

Tam et al’s4 meta-analysis study suggested that precise evaluation should include manometry and pH testing. Besides, patients with radiological hiatus hernia recurrence after surgery are often asymptomatic.2 In other words, it is claimed that any anatomical failure after hiatus hernia repair is relevant but whether this translates into the recurrence of symptoms remains unclear.5 In our opinion, both objective evidence and associated symptoms must be considered to define a “true” recurrent hernia, despite most of the symptoms observed after surgery being secondary symptoms and not associated with the recurrence.

Apart from the hernia repair’s integrity, the postoperative quality of life should also be considered seriously. It is common knowledge that laparoscopic fundoplication could substantially improve the quality of life related to gastroesophageal reflux symptoms.6 Rudolph-Stringer et al7 demonstrated good clinical outcomes after Nissen fundoplication, with nearly 90% of patients responding a better reflux symptom control and affirming the long-lasting effectiveness of antireflux surgery at follow-up of up to 20 years. Thus, it is essential to consider all preoperative and postoperative symptoms, objective findings, and impact on patients’ quality of life to indicate the appropriate treatment. Surgery has contributed to continued improvements in quality of life regardless of recurrence. Recurrence took place successively over ten years and might incline to the development of esophagitis.3 Thus, a global measure of outcomes should integrate symptom control, quality of life improvements, and related surgical side effects in determining surgical success.

More and more surgeons have applied the mesh materials for tension-free repair of the hiatus in recent years. However, tension-free mesh cruroplasty conferred some advantages and disadvantages. The mesh-related scarring process could lead to esophageal stenosis, abscess, or fistula formation. For instance, a recent survey pointed out that the incidence of mesh erosion and esophageal stenosis were 21% and 25%, respectively. Interestingly, when stratifying the analysis by the type of mesh, we found that this higher overall morbidity was intrinsically related to the use of nonabsorbable mesh.2 Besides, Zhang et al6 mentioned that mesh application might lead to a lower short-term recurrence rate, and the biological mesh was affiliated with improved short-term quality of life. Nevertheless, these merits were negated by a higher incidence of dysphagia in their meta-analysis study.6

Following hernia reduction, the muscle that makes up the diaphragmatic pillars is usually friable, offering poor support for primary closure.5 It is not surprising that the hiatus hernia’s sole primary repair by suturing the diaphragm’s weak pillars together under tension would significantly increase the risk for disruption. When we could not approximate the crura or could only perform the procedure under extreme tension, we should make a relaxing incision on the diaphragm to release the tension at the hiatus. However, there is no persuasive evidence to support the mesh-augmented hernia repair, though it is mandatory to cover a mesh on the diaphragmatic defect associated with the relaxing incision. Besides, some specialists also recommend proposed access into the pleural space to increase the diaphragmatic pliability and release any tension from an adhered lung.8

Le Page et al3 mentioned the impact of mesh use and gastropexy procedures on hiatus hernia recurrence. Higashi et al9 suggested laparoscopic anterior gastropexy as effective and safe for large hiatus hernias, especially in elderly patients. In our experience of 25 hiatus hernia patients complicated with chronic intra-thoracic gastric volvulus, we routinely performed laparoscopic repair for them, with an average age of 70.8 (range, 51–85) years. We used stout, interrupted, and nonabsorbable sutures to approximate both crura posteriorly, reinforced by one tiny piece of nonabsorbable mesh pledges (1 × 1 cm2) outside each stitch for crural muscle repair.10 We think this could reduce the risk of ischemic necrosis and subsequent failure of the crural repair. We did not place a large piece of prosthetic mesh across the hiatus defect for tension-free cruroplasty, and its associated complications could also be avoided.

Moreover, we routinely sutured the Nissen fundoplication’s fundic wrap to the right crus and retroperitoneum with nonabsorbable stitches, which would be sufficient for gastropexy to lower the recurrence rate. Our patients did not suffer from perioperative complications, and their chief complaints were resolved rapidly without the symptom of dysphagia or recurrence in the subsequent follow-up of median 42.5 months (range, 10–76 months). Our different gastropexy technique is an effective alternative and obviates gastrostomy for gastric fixation in the elderly.


1. Petric J, Bright T, Liu DS, et al. Sutured versus mesh-augmented hiatus hernia repair: a systematic review and meta-analysis of randomized controlled trials. Ann Surg. 2022;275:e45–e51.
2. Angeramo CA, Schlottmann F. Laparoscopic paraesophageal hernia repair: to mesh or not to mesh. Systematic review and meta-analysis. Ann Surg. 2022;275:67–72.
3. Le Page PA, Furtado R, Hayward M, et al. Durability of giant hiatus hernia repair in 455 patients over 20 years. Ann R Coll Surg Engl. 2015;97:188–193.
4. Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh vs suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016;211:226–238.
5. Analatos A, Håkanson BS, Lundell L, et al. Tension-free mesh versus suture-alone cruroplasty in antireflux surgery: a randomized, double-blind clinical trial. Br J Surg. 2020;107:1731–1740.
6. Zhang C, Liu D, Li F, et al. Systematic review and meta-analysis of laparoscopic mesh versus suture repair of hiatus hernia: objective and subjective outcomes. Surg Endosc. 2017;31:4913–4922.
7. Rudolph-Stringer V, Bright T, Irvine T, et al. Randomized trial of laparoscopic Nissen versus anterior 180 degree partial fundoplication - late clinical outcomes at 15 to 20 years. Ann Surg. 2022;275:39–44.
8. Inaba CS, Oelschlager BK.To mesh or not to mesh for hiatal hernias: what does the evidence say. Ann Laparosc Endosc Surg.2021;6:40.
9. Higashi S, Nakajima K, Tanaka K, et al. Laparoscopic anterior gastropexy for type III/IV hiatal hernia in elderly patients. Surg Case Rep. 2017;3:45.
10. Chiu CC, Wang W, Wei PL, et al. Giant diaphragmatic hernia with intrathoracic gastric volvulus. Endoscopy. 2006;38(Suppl 2):E52–E53.
Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.