Controversies Regarding Mesh Implantation for Hiatal Reinforcement in GERD and Hiatal Hernia Surgery

Many laparoscopic surgeons use mesh augmentation at the hiatus with nonresorbable or absorbable mesh currently. Substantial controversies are present, and surgical meetings often feature controversial discussions. Based on the available evidence, implantation of mesh in a regular GERD patient with a small to midsize hiatal hernia cannot be recommended as a routine procedure, since the advantages seem to be quite limited with recurrence and risk of long-term complication. In large hiatal hernias (>5 cm), current evidence and meta-analysis suggest that the use of a mesh can be considered, but the risk for complications is substantial and therefore the patient should be informed about these risks. Early results on bioabsorbable mesh are promising for reduction in early recurrence, but longer-term data is needed to determine the durability of the repair. In centers of antireflux surgery with a large experience in upper GI surgery, the use of a mesh may not reduce the necessity of revisional surgery even in large hiatal hernias. Therefore, the indication for mesh implantation should be tailored and focused to each individual patient. It is the opinion of the authors that permanent mesh should not be placed for hiatal reinforcement under any circumstance due to the potentially devastating consequences of erosion or frozen hiatus. Early reports of bioabsorbable mesh placement are promising, but require longer-term follow-up.