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Page 2 of 6 Bitner et al. Mini-invasive Surg 2022;6:46 https://dx.doi.org/10.20517/2574-1225.2022.46

with higher use of mesh at 92.1% of European surgeons at least selectively using mesh although mesh types
differed with most surgeons preferring either polypropylene, polyester or PTFE meshes and only 27.9%
[6]
using biologic meshes . In registry analyses, these survey results are further expanded: mesh is used
frequently but in less than half of ARS cases overall [7-10] . As for trends over time, in two National Surgery
Quality Improvement Program (NSQIP) analyses between 2010-2015, the use of mesh remained stable over
[7,8]
time at around 38%-43% . In registry analyses including the second half of the last decade, however,
results conflicted. In an NSQIP analysis between 2010-2017 of over 25,000 cases, mesh utilization decreased
[9]
from 46.2% to 35.2% . In a European analysis between 2010 - 2019, mesh utilization for axial HHR was
stable at ~20%, for paraesophageal HHR mesh increased from 33% to 38.9%, and was stable for recurrent
HHR at around 45% .
[10]

Professional society recommendations and directions
The heterogeneous practice patterns in ARS are reflected in recent reviews and in professional society
guidelines. In the SAGES Guideline on general Surgical Treatment of GERD from 2021, mesh use is not
discussed, but in its Guideline on Management of Hiatal Hernia Repair in 2013, mesh is recommended for
large HH based on several randomized controlled trials (RCT), although long-term data is noted to be
insufficient beyond the short follow-up interval of the available RCTs as of 2013 [11,12] . In this chapter, we will
review the most recent data underlying the subscription to mesh use in ARS as well as more specific
considerations of mesh implementation in ARS.

Hiatal hernia repair
Highest level of data - the meta-analyses of suture vs. mesh in HHR
In general, mesh utilization in ARS is most relevant in HHR. Given the publication of several RCTs about
mesh utilization in HHR since the most recent SAGES guidelines, multiple meta-analyses have subsequently
been published [Table 1] [13-25] . Although results from earlier meta-analyses might suggest benefits for mesh
placement, it should be noted that most early studies include observational data. Two recent meta-analyses
are consistent in evaluating the same 7 RCTs only (no observational data included), and both find no
advantage to the use of mesh in HHR [13,14] . Caution in interpreting the meta-analytic data is advised as the
RCTs included are heterogeneously conducted (see next section).

A granular look at the RCTs conduct on mesh utilization in HHR
As can be seen in the table below, the heterogeneity of available RCTs studying mesh placement in HHR
since 2000 is noteworthy [Table 2] [26-32] , especially when considering years of follow-up and the type of mesh
used. Two studies used biologic meshes and the other five used non-absorbable meshes. Additionally, the
studies frequently define inclusion size for HH differently. Of note, the two largest, most recent studies both
show no definite advantage with mesh utilization [26,27] . This likely accounts for the differences seen in the
most recent meta-analyses compared to those from prior years.

Observational data in mesh placement during HHR
Although many observational studies have been published on mesh use in HHR, few add to the RCTs and
meta-analyses discussed previously. Heterogeneity is the rule with little standardization across the board,
but a few observational studies stand out. The largest observational study featured 795 patients; the mesh-
repair group featured mostly biologic mesh . This study agreed with the findings of metanalyses of RCTs
[33]
[33]
in that there was no long-term difference in recurrence between mesh-based and suture-based HHR . In
the only study of any style to our knowledge that discusses financial cost, several biologic meshes are
compared and the lowest recurrence rate is shown for human tissue matrix at 6 months but not at longer
intervals . With respect to cost in this study, porcine tissue matrix is the most costly and biosynthetic mesh
[34]
is the least costly, but no cost comparison was made with the non-absorbable meshes or suture-based