The controversial impact of mesh augmentation on surgical outcomes in hiatal hernia repair: A Systematic Review and Meta-analysis.

BACKGROUND: The role of mesh reinforcement in hiatal hernia repair remains controversial, with conflicting evidence regarding its effect on recurrence and overall morbidity. This systematic review and meta-analysis of randomized controlled trials and prospective cohorts aimed to compare mesh-augmented versus primary suture repair with regard to surgical outcomes. METHODS: A systematic search of the literature using MEDLINE (PubMed), EMBASE, and digital libraries was conducted to identify randomized controlled trials and prospective cohort studies comparing mesh-augmented and suture-only hiatal hernia repair. Seven RCTs involving 735 patients and three prospective studies involving 737 patients were included. The primary outcome was hernia recurrence, while secondary outcomes included postoperative complications, operative time and reoperation rates. Subgroup analysis was performed based on the type of complication and the type of study for recurrence. Pooled odds ratios (OR) were calculated using a random effects model, with heterogeneity assessed using the I2 statistic and prediction intervals (PI). RESULTS: Data on recurrence rates were available for 1472 patients, 681 (46.3%) who underwent mesh reinforcement and 791 (53.7%) primary repair. No significant difference in recurrence rate was observed between the two groups, with moderate heterogeneity (OR 0.51, 95% CI 0.25 - 1.03, 95% PI 0.08 - 3.35, I2= 49.6%). There was no significant difference in overall postoperative complications between mesh and primary repair (OR 1.07, 95% C.I. 0.6-1.92, 95% PI 0.32-3.6, I2=8.9%). Subgroup analysis based on type of study and follow-up period for recurrence and type of complication such as bleeding, perforation, or pneumothorax showed no significant differences. Reoperation rates were also comparable between the two groups (OR 0.43, 95% C.I. 0.17-1.11, 95% PI 0.12-1.50, I2 0.0%). CONCLUSION: Mesh augmentation of the hiatus in hiatal hernia repair does not significantly increase postoperative complications and does not decrease recurrence rate compared to cruroplasty alone based on the existing literature. Given the observed heterogeneity and wide prediction intervals, further high-quality randomized trials with standardized surgical techniques, accurate assessment of the hernia size and hiatal defect and long-term follow-up may further enlighten the comparison.