META-ANALYSIS

Sutured Versus Mesh-augmented Hiatus Hernia Repair

A Systematic Review and Meta-analysis of Randomized Controlled Trials
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM

Josipa Petric, MD, BMedSc,  yY Tim Bright, MBBS, MS, FRACS,y

i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023

David S. Liu, MBBS (Hons), BMedSc, PhD, FRACS,yz Melissa Wee Yun, MD, BMedSc,y
and David I. Watson, MBBS, MD, PhD, FRACS, FRCSEd (Hon), FAHMS  y

repair the hiatus using sutures, and then perform a fundoplication.2,3

Objective: This meta-analysis systematically reviewed published random-
However, approximately a third of these patients will develop a
ized control trials comparing sutured versus mesh-augmented hiatus hernia
radiological hernia recurrence by 5 years postsurgery, albeit most
(HH) repair. Our primary endpoint was HH recurrence at short- and long-term
being asymptomatic.4,5 The potential for asymptomatic recurrences
follow-up. Secondary endpoints were: surgical complications, operative
needing complex revisional surgery in the future remains a concern
times, dysphagia and quality of life.
for many clinicians. To address this, tension-free mesh-augmented
Summary Background Data: Repair of large HHs is increasingly being
hernioplasty, analogous to those used to repair groin and abdominal
performed. However, there is no consensus for the optimal technique for hiatal
wall hernias, has been proposed as a solution to reduce the risk of
closure between sutured versus mesh-augmented (absorbable or nonabsorb-
recurrence. Synthetic absorbable and nonabsorbable meshes for
able) repair.
hiatal closure have now been studied in randomized control trials
Methods: A systematic review of Medline, Scopus (which encompassed
(RCTs).
Embase), Cochrane Central Register of Controlled Trials, Web of Science,
Since the first application of mesh around the esophageal
and PubMed was performed to identify relevant studies comparing mesh-
hiatus,6 it has become evident that the use of mesh is not without a
augmented versus sutured HH repair. Data were extracted and compared by
risk of serious complications. These include esophageal erosion,
meta-analysis, using odds ratio and mean differences with 95% confidence
stenosis and fibrosis leading to ongoing dysphagia, and chest pain.7
intervals.
Furthermore, the presence of mesh makes revisional surgery more
Results: Seven randomized control trials were found which compared mesh-
challenging.8 Given these concerns, it remains unclear whether
augmented (nonabsorbable mesh: n ¼ 296; absorbable mesh: n ¼ 92) with
mesh-augmented hiatal closure offers a net benefit through reducing
sutured repair (n ¼ 347). There were no significant differences for short-term
the long-term risk of hernia recurrence and improving patients’
hernia recurrence (defined as 6–12 months, 10.1% mesh vs 15.5% sutured, P
quality-of-life (QOL).
¼ 0.22), long-term hernia recurrence (defined as 3–5 years, 30.7% mesh vs
Several meta-analyses comparing sutured versus mesh-aug-
31.3% sutured, P ¼ 0.69), functional outcomes and patient satisfaction. The
mented hiatal closures have been published previously.9– 13 Unfor-
only statistically significant difference was that the mesh repair required a
tunately, these meta-analyses are limited as none include all of the
longer operation time (P ¼ 0.05, OR 2.33, 95% confidence interval 0.03–
current RCTs, they only report short-term outcomes, and usually
24.69).
include nonrandomized case-control studies. As such, they have
Conclusions: Mesh repair for HH does not offer any advantage over sutured
reported conflicting results, and it is challenging to translate their
hiatal closure. As both techniques deliver good and comparable clinical
conclusions into clinical practice. Since the last published meta-
outcomes, a suture only technique is still an appropriate approach.
analysis, 2 new RCTs have been reported, and longer-term outcomes
Keywords: hiatal hernia, laparoscopic method, mesh-augmented repair, are also now available from sufficient RCTs to draw conclusions
randomized controlled trials, suture repair about the longer-term impact of mesh.14,15 This new data offers a
novel opportunity to meta-analyze only high-quality evidence exam-
(Ann Surg 2022;275:e45–e51)
ining both short- and long-term outcomes following sutured versus
mesh-augmented hiatal hernia repairs.
T he number of large hiatus hernia (HH) repairs has increased
significantly over the last 3 decades.1 The optimal technique for
hiatal closure, either sutured or mesh-augmented (absorbable or
Here, we meta-analyzed all published RCTs comparing
sutured versus mesh-augmented HH repair, to determine whether
mesh placement affects hernia recurrence in the short- and long-term,
nonabsorbable) repair, however, remains controversial. as well as its impact on surgical complications, operative time,
Developed in the 1990s, the standard laparoscopic approach to dysphagia, and quality of life.
large HH repair is to dissect the hernial sac from the mediastinum,
METHODS
This meta-analysis was conducted according to the recom-
From the College of Medicine and Public Health, Flinders University, South
Australia, Australia; yDepartment of Surgery, Flinders Medical Centre,
mendations of the preferred reporting of systematic reviews and
South Australia, Australia; and zDepartment of Surgery, Austin Hospital, meta-analyses (PRISMA) statement.16 It was also submitted for
Victoria, Australia. registration with PROSPERO.
josipa.petric@flinders.edu.au.
The authors report no conflicts of interest. Literature Search Strategy
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of A comprehensive search strategy of the following electronic
this article on the journal’s Web site (www.annalsofsurgery.com). databases for relevant RCTs were conducted: Medline, Scopus
Copyright ß 2021 Wolters Kluwer Health, Inc. All rights reserved. (which encompassed Embase), Cochrane Central Register of Con-
ISSN: 0003-4932/21/27501-0e45
DOI: 10.1097/SLA.0000000000004902
trolled Trials, Web of Science, and PubMed. The strategy was

Annals of Surgery  Volume 275, Number 1, January 2022 www.annalsofsurgery.com | e45

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Petric et al
composed of 4 components to identify: the disease (eg, MeSH term
‘‘hernia, hiatal’’ OR ‘‘esophageal hernia’’ OR ‘‘paraesophageal
hernia’’ OR ‘‘sliding hernia’’ ‘‘gastroesophageal reflux’’ and lan-
guage variations of this), the surgical procedure (eg, MeSH term
‘‘laparoscopy’’ OR ‘‘Laparoscop’’ OR ‘‘laparoscop surgery’’ OR
‘‘minimally invasive’’ OR ‘‘Nissen fundoplication’’ OR ‘‘fundopli-
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
cation’’), the intervention (eg, MeSH term ‘‘Surgical mesh’’ OR
‘‘mesh’’ or ‘‘implant’’ or ‘‘patch’’) and the study type (eg, ‘‘random-
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023
ized control trial’’ and variations). Studies were included from
January 1966 until November 2020. There was no language restric-
tion applied. A manual search of the reference lists of other articles
was also performed to identify any missed studies.
Eligibility Criteria
Title and abstracts of the identified articles were analyzed.
Their quality and eligibility for inclusion was assessed by 2 authors
(JP and MYW) using Covidence systematic review software (Veritas
Health Innovation, Melbourne, Australia). Appropriateness and
inconsistencies were resolved through discussions with senior
authors (DSL, TB, and DIW). Studies in the final analysis must
have included data on at least one of the mesh types compared to
sutured repair in at least 1 clinically relevant outcome. Final analyses
were run on outcome variables where data were sufficient across at
least 2 studies to allow statistical analysis.
Inclusion and Exclusion Criteria
Inclusion criteria were: (1) RCTs in patients who underwent
repair of HH with the use of mesh (absorbable or nonabsorbable)
compared to sutured repair, (2) duration of follow-up was greater
than 12 months, which may have been reported in a subsequent
follow-up study, (3) age 18 years, and (4) subjects were human.
Exclusion criteria were: (1) study types other than RCTs (systematic
reviews, retrospective and observational studies, commentaries/let-
ters, etc) (2) RCTs which did not compare at least 1 type of mesh
repair to a sutured hiatal hernia repair (3) RCTs in which patients
underwent surgery for an indication that was not consistent with
hernia repair or reflux control as the primary indication (eg, gastric
sleeve resection for obesity).
Methodological Quality
The Cochrane risk of bias tool was used to assess the meth-
odological quality of the identified RCTs.17
Data Extraction
Outcome data was extracted by 2 authors (JP and DSL) from the
final publication list. The data were integrated using Review Manager
5.4 (The Nordic Cochrane Centre, Copenhagen, Denmark) provided by
the Cochrane Collaboration. Data on HH recurrence was not published
in 1 study,18 so this data was extracted from a previous systematic review
which documented correspondence with the author group.7
Outcomes of Interest
Two study groups were compared: patients who underwent HH
repair with sutured versus mesh-augmented (absorbable or nonabsorb-
able mesh) hernia repair. The 6 outcome variables analyzed included:
1. Recurrence of HH in the short-term, with subgroup analysis for
the type of mesh (absorbable and nonabsorbable). Short-term was
defined as 6 to 12 months postsurgery. In cases where multiple
time points were assessed, the maximum time was selected.
2. Recurrence of HH in the long-term, with subgroup analysis for
the type of mesh (absorbable and nonabsorbable). Long-term was
defined as 3 to 5 years postsurgery. In cases where multiple time
points were assessed, the maximum time was selected.
e46 | www.annalsofsurgery.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 275, Number 1, January 2022
3. Total complications, with separate analyses of major complica-
tions, defined as any return to the operating room, mortality, or
intensive care admission. An inclusive definition was also con-
sidered for analysis where ‘‘major’’ complications included:
cardiac, pulmonary, and gastric complications, in addition to
return to theatre and mortality.
4. Incidence of dysphagia: dichotomous ‘‘yes/no’’ and visual analog
score (VAS) analysis.
5. Operative time, measured in minutes.
6. Meta-analysis of QOL measured by Short-Form 36 (SF-36).
7. Satisfaction score, measured using a 0 to 10 VAS.
Statistical Analysis
Data were pooled for meta-analysis. Odds ratio (OR) was used
for dichotomous outcomes and weighted mean differences for con-
tinuous outcome measures. The Mantel-Haenszel random-effects
model was used to measure the pooled OR with 95% confidence
intervals (CI), to establish the effect of each type of repair on the risk
of HH recurrence in both the short- and long-term, total complica-
tions and incidence of dysphagia. The inverse variance method was
used to pool continuous variables such as the operative time and
aspects of QOL. Variability in the data was assessed by determining
the heterogeneity among studies, using the I2 statistic. The I2 value
describes what proportion of the variance in the studies is due to
variation in real effects rather than sampling error.19 If heterogeneity
was relatively small (I2 < 50%), the fixed-effects model was then
used instead of the random-effects model. Some of the published
clinical trials did not report the standard deviations of the continuous
outcomes and some of the means needed to be combined, so using the
confidence intervals and formulas proposed by Cochrane the stan-
dard deviations and combined results were derived.20 In the case of
patient satisfaction, 1 study applied a trinomial scale rather than
using VAS scores from 0 to 10, so each of the three categories were
assigned a number out of 10 (poor ¼ 1/10, fair ¼ 4/10 and excellent/
good ¼ 8/10).21
RESULTS
Included Studies
The database search retrieved 394 publications, including 7
RCTs,14,18,21–25 from 2002 to 2020 which met the inclusion criteria,
and a further 2 studies containing later follow up data from 2 of the
RCTs which were also included in the meta-analysis. The PRISMA
flow chart for the literature search is shown in Figure 1. Two
additional RCTs were excluded as one did not have a sutured control
group, and the other did not determine hernia recurrence rates. In
total, across the 7 included RCTs, 735 patients were included, 347
with sutured hernia repair, 296 with nonabsorbable mesh-augmented
repair and 92 with absorbable mesh-augmented repair. The duration
of follow-up varied from 6 to 60 months. The study characteristics
are summarized in Table 1.
Bias Assessment
Figure S1, http://links.lww.com/SLA/D74 summarizes the
potential sources of bias for the RCTs, with all falling into ‘‘low
risk’’ of bias for most of categories. Four of the 7 studies were limited
by a lack of description of the randomization and/or blinding
processes in the methods,18,21–23 whereas this was explicit in 3 of
the 7 RCTs.14,24,25
Recurrence of HH
The short-term recurrence rate at 6 to 12 months was 10.1%
following mesh repair compared to 15.5% following sutured repair
ß 2021 Wolters Kluwer Health, Inc. All rights reserved.
 Annals of Surgery  Volume 275, Number 1, January 2022
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023
FIGURE 1. PRISMA flow diagram which outlines the literature assessment.
(OR 0.56, 95% CI 0.24–1.35), with evidence of moderate heteroge-
neity (x2 ¼ 14.26, P ¼ 0.03, I2 ¼ 58%). There was no statistically
significant difference between these 2 groups (P ¼ 0.20). Subgroup
analysis was undertaken to determine if there was a difference
between the 2 mesh types compared to sutured repair. Two studies
compared absorbable mesh to sutured repair and 6 studies compared
nonabsorbable mesh to sutured (one compared both).24 There was a
7.6% recurrence in the nonabsorbable mesh group compared to
14.3% in the sutured repair group (OR 0.53, 95% CI 0.17–2.51),
and 17.8% recurrence in the absorbable mesh compared to 21.9% in
the sutured repair group (OR 0.71 95% CI 0.16–3.21). There was no
difference in heterogeneity between these two arms (x2 ¼ 0.1, P ¼
0.75, I2 ¼ 0%) or statistically significant differences for the primary
outcome (P ¼ 0.75). The corresponding Forest plots of ORs are
presented in Figure 2 and Figure S2, http://links.lww.com/SLA/D74.
ß 2021 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Suture Versus Mesh for Hiatus Hernia Repair
Long-term follow-up at 3 to 5 years, was available for 4 studies.
There was no significant difference between the mesh versus sutured
repair groups (P ¼ 0.69), with a 30.7% recurrence rate in the mesh
group versus 31.3% in the sutured repair group (OR 0.83, 95% CI
0.34–2.05). There was evidence of moderate heterogeneity (x2 ¼ 6.71,
P ¼ 0.08, I2 ¼ 55%). Subgroup analysis was undertaken to determine if
there was a difference between the 2 mesh types compared to sutured.
Three studies compared nonabsorbable mesh to sutured repair and 2
studies compared absorbable mesh to sutured repair (1 compared
both).15 The nonabsorbable mesh subgroup analysis found an
18.2% recurrence rate in the mesh group compared to a 22.7%
recurrence in the sutured repair group (OR 0.66, 95% CI 0.17–
2.51). The absorbable mesh subgroup analysis found a 49.2% recur-
rence in the mesh group compared to a 46.3% recurrence in the sutured
repair group (OR 1.16, 95% CI 0.41–3.27). The corresponding Forest
www.annalsofsurgery.com | e47
 Petric et al Annals of Surgery  Volume 275, Number 1, January 2022

TABLE 1. Study Characteristics

Year of First Study Numbers Total Mean Age Type of Mesh Short-term Long-term
Author Publication Country (Mesh/Sutured) Mesh/Sutured (yr) Follow-up (mo) Follow-up (mo)
Analatos et al 2020 Sweden 82/77 55/53 Nonabsorbable 3–12 36
Frantzides et al 2002 USA 36/36 63/58 Nonabsorbable 6–72 n/a
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM

Granderath et al 2005 Germany 50/50 48/48 Nonabsorbable 3–12 n/a

Ilyashenko et al 2018 Ukraine 50/48 63/63 Nonabsorbable 3–12 36–60
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023

Oelschlager et al 2006 USA 51/57 67/64 Absorbable 6 9–59

Oor et al 2018 The Netherlands 36/36 62/64 Nonabsorbable 3–12 n/a
Watson et al 2015 Australia 83/43 68/68 Nonabsorbable/ 3–12 36–60
absorbable

plots of ORs are presented in Figure 3 and Figure S3, http://link-
s.lww.com/SLA/D74.
Postoperative Complications
Overall complication rates (summation of all major and minor
complications which were reported) were 15.0% for the mesh repair
group and 13.8% for the sutured repair group (OR 1.11, 95% CI
0.72–1.71), with no significant difference between the groups (P ¼
0.63) or heterogeneity (x2 ¼ 5.13, P ¼ 0.4, I2 ¼ 2%) (Figure S4,
http://links.lww.com/SLA/D74). When focusing on major compli-
cations, there were 2 definitions which were analyzed: one was
inclusive and one more targeted. The inclusive analysis found no
significant difference between the mesh and sutured repair groups (P
¼ 0.22). The rates were 11.1% in the mesh group and 11.0% in the
sutured repair group (OR 1.01, 95% CI 0.63–1.62), with small levels
of heterogeneity between the groups (x2 ¼ 5.71, P ¼ 0.22, I2 ¼ 30%).
These results are available in Figure S5, http://links.lww.com/SLA/
D74. The targeted analysis yielded similar results with no significant
difference in the rate of major complications between the mesh
(1.6%) and sutured (2.3%) repair groups (P ¼ 0.20, OR 0.49, 95% CI
0.16–1.46). The data showed no evidence of statistical heterogeneity
between the groups (x2 ¼ 0.31, P ¼ 0.86, I2 ¼ 0%). These results are
found in Figure 4.
Dysphagia
Four out of 7 studies evaluated symptoms of dysphagia. All 4
used a VAS score, and 2 of the 4 also used a binary ‘‘yes/no’’ system.
Both were analyzed and data are shown in Figure 5 and Figure S6,
http://links.lww.com/SLA/D74. The binary data showed that the
mesh group had a dysphagia rate of 7.0% and 9.2% for the sutured
repair group (P ¼ 0.56, OR 0.73, 95% CI 0.26–2.07). Similarly, there
was no significant difference between the mesh and the sutured repair
group for the VAS analysis (P ¼ 0.39), both sets of data showed no
heterogeneity between comparison groups (I2 ¼ 0% for both sets of
data).
Operative Time
The operative time was reported by 6 of the 7 studies, whereas
one was ‘‘not estimable’’ for the analysis as there was insufficient
data. There was a significant difference (P ¼ 0.05, OR 12.33, 95% CI

FIGURE 2. Forest plot of odds ratio of early hernia recurrence – subgroup analysis for nonabsorbable mesh groups compared to
suture groups (1.2.1), and absorbable mesh groups compared to suture groups (1.2.2). The total overall outcome for all mesh types
is also displayed.

e48 | www.annalsofsurgery.com ß 2021 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Annals of Surgery  Volume 275, Number 1, January 2022 Suture Versus Mesh for Hiatus Hernia Repair
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023

FIGURE 3. Forest plot of odds ratio of late hernia recurrence – subgroup analysis for nonabsorbable mesh groups compared to
sutured groups (2.2.1), and absorbable mesh groups compared to sutured groups (2.2.2). The total overall outcome for all mesh
types is also displayed.

0.03 to 24.69) between the mesh group and the sutured repair
group, with the mesh group having a longer operative time. The data
had a high level of heterogeneity (I2 ¼ 76%) (Figure S7, http://
links.lww.com/SLA/D74). If the oldest study is removed from the
analysis, as it was the only study showing a significant difference
between its arms,18 a significant difference remains between the
mesh and sutured groups (P ¼ 0.05, OR 4.91, 95% CI 0.11–9.71).
There was no heterogeneity in this modified dataset (I2 ¼ 0%). All
analyses are available in Figure S8, http://links.lww.com/SLA/D74.
there was an improvement in the score from baseline, however, there
was no reported statistically significant difference between the mesh
and sutured repair groups.22 A long-term follow-up of this RCT also
concluded the same: that there was an improvement from baseline
but no statistically significant difference between the groups.26 The
final study also found that all of study groups showed a difference in
the physical and mental component scores from baseline to short-
term follow-up, but there were no significant differences between the
study groups at short-term follow-up.27

Quality of Life Satisfaction Score

Each of the studies assessed QOL differently, and thus not
meta-analyzable. Of the 3 that used the SF-36, 1 presented data
which showed that there was an improvement after surgery in the
physical and mental component scores, but there was no significant
difference between the mesh and sutured groups in the short- and
long-term.14 Another study also noted that at short-term follow-up,
The satisfaction score was reported in 3 studies for the sutured
and mesh group and there was no difference between the groups (P ¼
0.82). Two of these studies used a 0 to 10 VAS, whereas 1 was
estimated from the trinomial system as described above.21 There was
no heterogeneity in this data set groups (x2 ¼ 0.35, P ¼ 0.84, I2 ¼
0%). These results are found in Figure 6.

FIGURE 4. Forest plot of odds ratio of all major complications (defined as any return to theatre OR mortality OR ICCU admission) for
mesh groups compared to sutured groups.

ß 2021 Wolters Kluwer Health, Inc. All rights reserved. www.annalsofsurgery.com | e49

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Petric et al
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023
FIGURE 5. Forest plot of odds ratio of occurrence of dysphagia (short-term VAS scores) for mesh groups compared to sutured
groups. ICCU indicates intensive coronary care unit.
FIGURE 6. Forest plot of odds ratio of patient satisfaction scores (a scale from 0 to 10) for mesh groups compared to sutured groups.
DISCUSSION
This meta-analysis found no differences in outcomes for
patients who underwent HH repair with mesh compared to sutures
alone. The lack of significant differences was for short-term out-
comes of hernia recurrence, postoperative complications, dysphagia,
QOL and satisfaction scores, and also for longer term follow-up.
Taken together, these findings failed to show a benefit for mesh-
augmented repair or that it is superior to sutured repair of the hiatus
alone. These findings do not support routine use of mesh around the
esophageal hiatus, and it follows that more compelling evidence is
required before a position of routine mesh repair should be proposed.
Our study is the first to analyze only RCTs comparing short-
and long-term outcomes of mesh versus sutured repair of the hiatus.
Other meta-analyses typically merged randomized and nonrandom-
ized data, opening up these previous meta-analyses to selection
bias.10–12 Additionally, the previous studies presented short-term
outcomes, and were limited in their analysis of QOL, dysphagia and
patient satisfaction. Our study addressed these shortcomings by
including 2 new RCTs, which provided sufficient power to draw
conclusions from only the highest level of evidence.14,15 Addition-
ally, for the first time we were also able to analyze longer term
objective outcomes. Further, in contrast to previous meta-analyses,
our study compared different types of mesh-augmentation with
sutured hiatal closure, thus demonstrating that mesh reinforcement,
regardless of material type, offers no added protection against hernia
recurrence in both the short- and long-term.
Previous studies have concluded that mesh-augmented repair
may be superior to sutured closure alone in preventing hernia
recurrence.9 –11 These studies, however, did not include all of the
RCTs included in our study. Moreover, by solely focusing on RCTs
our conclusions are methodologically more robust, than previous
studies which have included nonrandomized studies.
In this study, we performed a multifaceted meta-analysis of
postoperative complications. Consistent with other studies, we found
that there were no differences in overall adverse events between both
groups.9,11,12 Similarly, rates of dysphagia, patient QOL, and satis-
faction scores were also comparable between the 2 groups. In line
e50 | www.annalsofsurgery.com
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Annals of Surgery  Volume 275, Number 1, January 2022
with previous reports, the only outcome which was significantly
different between the mesh and sutured groups was operative time,
which was shorter in the sutured group.9,10 This difference was most
evident in the study by Frantzides et al,28 which also happened to be
the oldest.28 From this perspective, it could be argued that perhaps
the longer operating times in the mesh group may reflect the initial
learning curve of mesh placement. Nonetheless, when this study was
excluded a significant difference in operative time between the 2
groups remained. Therefore, it stands to reason that placing and
securing a mesh is more time consuming.
Traditionally, a risk of mesh-related complications such as
esophageal erosion has been accepted as a trade-off for the perceived
benefit of minimizing hernia recurrence. Previously case series have
described instances of mesh erosion, as well as more difficult
revision surgery in individuals who had undergone previous repair
with mesh,7,28 although it should be recognized that mesh related
complications were not reported in any of the trials included in the
current meta-analysis. Nevertheless, as the findings from our study
failed to demonstrate a benefit for routine mesh use, it still seems
sensible to recommend an approach which minimizes the risk of
mesh related complications. The failure of mesh or sutured repair to
fully eliminate a risk of hernia recurrence, suggests an inevitable
reoperation risk of up to 5% to 10% for hernia recurrence persists
irrespective of the repair technique applied. In view of this risk, it
seems sensible to maximize the ease of reoperating around the hiatus.
This includes avoiding mesh during the primary hiatal repair to
reduce the risk of dense adhesions which render revisional surgery
more challenging. Moreover, we suggest surgeons should focus on
ensuring a sound sutured repair is achieved in the first instance. This
involves complete dissection of the hernia sac away from the
mediastinum, full reduction of sac and contents back into the
abdominal cavity, meticulous preservation of the fascial coverings
overlying the left and right hiatal pillars, hiatal apposition in a
tension-free manner, and an appropriate fundoplication to anchor
the abdominal esophagus and stomach below the diaphragm.
A limitation of our study is the heterogeneity between differ-
ent RCTs. This includes surgical technique, definitions of hernia size,
ß 2021 Wolters Kluwer Health, Inc. All rights reserved.
 Annals of Surgery  Volume 275, Number 1, January 2022
complication grading, dysphagia assessment, and timing of follow-
up. Meta-analyzing only data from RCTs should balance these
variables across the trials. Two of the 7 trials included patients with
smaller hernias, with 40% of the patients in the trial from Granderath
et al having hernias measuring less than 5 cm in length,23 and 64% of
the patients Analatos et al’s trial having hernias measuring less than
Downloaded from http://journals.lww.com/annalsofsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XM
4 cm.14 However, as the other 5 trials limited recruitment to patients
with very large hernias, a large majority of patients underwent repair
i0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 07/19/2023
of a hernia containing 50% to 100% of the stomach. Many of these
patients were also elderly. For example the mean age at surgery in the
trial reported by Watson et al was 68 years.24 Further, as the trials
enrolled individuals undergoing primary HH repair, results should
not be applied in individuals undergoing revisional surgery.
It might be contended that the results of our meta-analysis do not
reflect the outcomes from newer meshes, and that more ‘‘modern’’
mesh types might reduce the risk of recurrence. Such a view requires
support from additional randomized trials. Aview that a new mesh will
yield a different outcome to mesh types already evaluated is untested,
and an onus of proof rests with advocates of newer meshes with future
randomized trials demonstrating different outcomes required.
In conclusion, this meta-analysis suggests that there are no
significant differences between mesh and sutured hiatal hernia repair,
apart from operation time. In both the short- and long-term, there
were no statistically significant differences between the different
repair techniques for hiatal hernia recurrence risk. In the short-term
there were also no differences in postoperative complications, occur-
rence of dysphagia, quality of life and patient satisfaction. As both
techniques deliver comparable clinical outcomes, a sutured tech-
nique for primary HH repair is simpler and should be recommended.
REFERENCES
1. Watson DI. Current state of repair of large hiatal hernia. Int J Abdom Wall
Hernia Surg. 2019;2:39–43.
2. Watson DI, Davies N, Devitt PG, et al. Importance of dissection of the hernial sac in
laparoscopic surgery for large hiatal hernias. Arch Surg. 1999;134:1069–1073.
3. Edye M, Salky B, Posner A, et al. Sac excision is essential to adequate
laparoscopic repair of paraesophageal hernia. Surg Endosc. 1998;12:1259–
1263.
4. Aly A, Munt J, Jamieson GG, et al. Laparoscopic repair of large hiatal hernias.
Br J Surg. 2005;92:648–653.
5. Smith GS, Isaacson JR, Draganic BD, et al. Symptomatic and radiological
follow-up after para-esophageal hernia repair. Dis Esophagus. 2004;17:279–
284.
6. Kuster GG, Gilroy S. Laparoscopic technique for repair of paraesophageal
hiatal hernias. J Laparoendosc Surg. 1993;3:331–338.
7. Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after pros-
thetic reinforcement of hiatal closure: a 28-case series. Surg Endosc.
2009;23:1219–1226.
8. Dallemagne B, Arenas Sanchez M, Francart D, et al. Long-term results after
laparoscopic reoperation for failed antireflux procedures. Br J Surg.
2011;98:1581–1587.
9. Memon MA, Siddaiah-Subramanya M, Yunus RM, et al. Suture cruroplasty
versus mesh hiatal herniorrhaphy for large hiatal hernias (HHs): an updated
ß 2021 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Suture Versus Mesh for Hiatus Hernia Repair
meta-analysis and systematic review of randomized controlled trials. Surg
Laparosc Endosc Percutan Tech. 2019;29:221–232.
10. Zhang C, Liu D, Li F, et al. Systematic review and meta-analysis of
laparoscopic mesh versus suture repair of hiatus hernia: objective and subjec-
tive outcomes. Surg Endosc. 2017;31:4913–4922.
11. Sathasivam R, Bussa G, Viswanath Y, et al. ’Mesh hiatal hernioplasty’ versus
’suture cruroplasty’ in laparoscopic para-oesophageal hernia surgery; a sys-
tematic review and meta-analysis. Asian J Surg. 2019;42:53–60.
12. Campos V, Palacio DS, Glina F, et al. Laparoscopic treatment of giant hiatal
hernia with or without mesh reinforcement: a systematic review and meta-
analysis. Int J Surg. 2020;77:97–104.
13. 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.
14. Analatos A, Hakanson 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.
15. Watson DI, Thompson SK, Devitt PG, et al. Five year follow-up of a
randomized controlled trial of laparoscopic repair of very large hiatus hernia
with sutures versus absorbable versus nonabsorbable mesh. Ann Surg.
2020;272:241–247.
16. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic
reviews and meta-analyses: the PRISMA statement. BMJ. 2009;339:b2535.
17. Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool
for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928.
18. Frantzides CT, Madan AK, Carlson MA, et al. A prospective, randomized trial
of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple crur-
oplasty for large hiatal hernia. Arch Surg. 2002;137:649–652.
19. Borenstein M, Higgins JP, Hedges LV, et al. Basics of meta-analysis: I(2) is not
an absolute measure of heterogeneity. Res Synth Methods. 2017;8:5–18.
20. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA
(editors). Cochrane Handbook for Systematic Reviews of Interventions. 2nd
Edition. Chichester (UK): John Wiley & Sons, 2019.
21. Ilyashenko VV, Grubnyk VV, Grubnik VV. Laparoscopic management of large
hiatal hernia: mesh method with the use of ProGrip mesh versus standard
crural repair. Surg Endosc. 2018;32:3592–3598.
22. Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces
recurrence after laparoscopic paraesophageal hernia repair: a multicenter,
prospective, randomized trial. Ann Surg. 2006;244:481–490.
23. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic Nissen
fundoplication with prosthetic hiatal closure reduces postoperative intratho-
racic wrap herniation: preliminary results of a prospective randomized func-
tional and clinical study. Arch Surg. 2005;140:40–48.
24. Watson DI, Thompson SK, Devitt PG, et al. Laparoscopic repair of very large
hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh:
a randomized controlled trial. Ann Surg. 2015;261:282–289.
25. Oor JE, Roks DJ, Koetje JH, et al. Randomized clinical trial comparing
laparoscopic hiatal hernia repair using sutures versus sutures reinforced with
non-absorbable mesh. Surg Endosc. 2018;32:4579–4589.
26. Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to
prevent recurrence after laparoscopic paraesophageal hernia repair: long-term
follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg.
2011;213:461–468.
27. Koetje JH, Irvine T, Thompson SK, et al. Quality of life following repair of
large hiatal hernia is improved but not influenced by use of mesh: results from
a randomized controlled trial. World J Surg. 2015;39:1465–1473.
28. Frantzides CT, Carlson MA, Loizides S, et al. Hiatal hernia repair with mesh: a
survey of SAGES members. Surg Endosc. 2010;24:1017–1024.
www.annalsofsurgery.com | e51