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).

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.

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^[33]. This study agreed with the findings of metanalyses of RCTs in that there was no long-term difference in recurrence between mesh-based and suture-based HHR^[33]. 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^[34]. With respect to cost in this study, porcine tissue matrix is the most costly and biosynthetic mesh is the least costly, but no cost comparison was made with the non-absorbable meshes or suture-based repair^[34].

In general, although when considering mesh usage in ARS one is discussing HHR, mesh can be used in non-HH-related ARS. In the only (small, n = 50) RCT to our knowledge in non-HH-related ARS comparing mesh- to non-mesh repairs, Muller-Stich et al. compared laparoscopic mesh-augmented hiatoplasty with cardiophrenicopexy (LMAH-C) with laparoscopic Nissen fundoplication (LNF) in patients with GERD but excluded those with Type II-IV HH^[35]. Considering endoscopy findings and symptom scores as primary endpoints, they showed that treatment failure with higher reflux-related symptom scores and esophagitis findings was worse in the LMAH-C arm compared to LNF^[35]. Although this is a demonstration of improved symptom control in non-HH-related ARS without the use of mesh, it is not clear that the lack of mesh is what was operative in this case as two different operations were compared independent of the mesh use or non-use: a gastropexy vs. a fundoplication. Generally, few data exist about mesh- vs. non-mesh repairs during non-HH-related ARS.

Little data exists comparing mesh- and non-mesh-based repairs of reoperative ARS. Many surgeons consider reoperation an indication of mesh usage, and so perhaps the lack of data owes to the suspected lack of equipoise^[4,9]. Nevertheless, in the only comparative study of mesh use in reoperative ARS - essentially a case series that discusses the use of mesh or not in reoperative ARS - Desai et al. found similar re-reoperation rates (16% vs. 20%) in mesh-based and non-mesh-based repairs of failed HHR (n = 82)^[36]. Additionally, some of the RCTs for HHR include reoperative HHR, but none provide subgroup analysis of this population^[27]. In general, the use of mesh in reoperative ARS has not been sufficiently studied.

Almost no data exist to guide the surgeon in choosing how to operate on the difficult population that presents with acute complicated HH, including gastric volvulus, perforation, or obstruction^[3]. No comparative studies comparing mesh and non-mesh-based repairs in complicated HH are available.

Finally, there are particular risks to the use of mesh not reflected in the apparently benign results in which no difference in complication rates is seen in mesh-based and non-mesh-based arms of RCTs in ARS. Mesh erosion is a feared complication in which the mesh burrows into the esophagus. Mesh erosion can present with dysphagia, abdominal pain, fistula, reduced oral intake, odynophagia, or weight loss. In a recent systematic review, the risk of this complication is about 0.035% of all ARS cases in which mesh is used, and non-biologic mesh is the more frequently associated culprit, with the complication generally occurring within 5 years of the procedure^[37].

Though perhaps less often considered, there is a more common reason to avoid mesh if it does not benefit the patient: cost. Although the dollars-and-cents cost of mesh usage was not reported in any of the RCTs and few observational studies, mesh has an obvious cost on top of the simple sutures that would otherwise be used for crural approximation during ARS. In the study cited previously, several biologic meshes are compared and the costs vary but do not seem to affect the overall charge^[34]. Aside from that report, however, very few data exist as to the financial cost-benefit analysis of mesh usage in ARS.