Recurrence rates after primary suture cruroplasty for large hiatal hernias were reported as high as 40-50% in radiologic studies, prompting investigation of mesh reinforcement to reduce recurrence. The hypothesis was that the mechanical stress on the crural closure could be distributed by a mesh prosthesis, similar to the paradigm shift that mesh introduced in inguinal hernia repair.

Granderath 20052005Landmark

Mesh reduced recurrence from 26% to 8% at 1 year (p=0.03); early evidence for mesh

Archives of surgery (Chicago, Ill. : 1960)RCTN=50

Proof

Landmark RCTs and pivotal trials that established the evidence base

Oelschlager and colleagues published the landmark multicenter RCT comparing biologic mesh (small intestinal submucosa) reinforcement to primary suture repair for laparoscopic paraesophageal hernia repair. Among 108 randomized patients, mesh reduced radiologic recurrence at 6 months (9% vs 24%, p=0.04). However, a critical follow-up study at 5+ years showed the early advantage disappeared — recurrence rates were similar in both groups at longer follow-up. This finding undermined the biologic mesh argument and highlighted the distinction between early anatomic recurrence and clinically relevant outcomes.

Oelschlager Biologic Mesh2006Landmark

Radiologic recurrence at 6 months — mesh 9% vs suture 24% (p=0.04); advantage lost at 5-year follow-up

Ann SurgRCTN=108

Extension

Follow-up studies, subgroup analyses, and real-world validation

A Swedish RCT with 13-year follow-up (2023) evaluated nonabsorbable PTFE mesh versus suture cruroplasty in hiatal hernia repair during antireflux surgery. Recurrence rates were 38% (mesh) vs 31% (suture), with no significant difference. Importantly, the mesh group had higher dysphagia scores. Additional RCTs with nonabsorbable mesh also failed to demonstrate consistent long-term benefit, and mesh-related complications (erosion, stricture, dysphagia) raised safety concerns. These findings indicated that mesh reinforcement — whether biologic or synthetic — did not reliably reduce hiatal hernia recurrence long-term and could introduce additional morbidity.

Swedish 13-Year Follow-up2024Landmark

Radiologic recurrence at 13 years — mesh 38% vs suture 31% (NS); higher dysphagia with mesh

JAMA surgeryRCTN=64

Guidelines

Integration into clinical practice guidelines and recommendations

Current guidelines do not recommend routine mesh reinforcement for hiatal hernia repair. SAGES guidelines suggest that mesh may be considered for very large hernias with significant crural defects but acknowledge the lack of long-term benefit evidence and potential for mesh-related complications.

SAGES

Routine mesh reinforcement not recommended; may be considered selectively for very large defects; surgeon judgment paramount

EAES

Insufficient evidence to recommend routine mesh use; primary suture repair remains standard

Now

Current standard of care and ongoing research directions

The evidence does not support routine mesh reinforcement for hiatal hernia repair. Short-term benefits with biologic mesh (Oelschlager) did not persist at 5 years, and long-term data with synthetic mesh show no benefit and potential harm (dysphagia). Primary suture cruroplasty remains the standard approach. Research continues into novel fixation techniques, absorbable mesh alternatives, and better understanding of why radiographic recurrence often has minimal clinical impact.

Landmark Trials in This Story

Granderath 20052005Landmark

Laparoscopic Nissen fundoplication with prosthetic hiatal closure reduces postoperative intrathoracic wrap herniation: preliminary results of a prospective randomized functional and clinical study

Mesh reduced recurrence from 26% to 8% at 1 year (p=0.03); early evidence for mesh

Archives of surgery (Chicago, Ill. : 1960)RCTN=50

Oelschlager Biologic Mesh2006Landmark

Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial

Radiologic recurrence at 6 months — mesh 9% vs suture 24% (p=0.04); advantage lost at 5-year follow-up

Ann SurgRCTN=108

Swedish 13-Year Follow-up2024Landmark

Hiatal Hernia Repair With Tension-Free Mesh or Crural Sutures Alone in Antireflux Surgery: A 13-Year Follow-Up of a Randomized Clinical Trial

Radiologic recurrence at 13 years — mesh 38% vs suture 31% (NS); higher dysphagia with mesh

JAMA surgeryRCTN=64

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Frequently Asked Questions

Does mesh reduce recurrence after hiatal hernia repair?+

Short-term data showed benefit: the Oelschlager RCT (108 patients) found mesh reduced 6-month recurrence from 24% to 9%. However, this advantage disappeared at 5+ year follow-up. A Swedish 13-year RCT found equivalent recurrence (mesh 38% vs suture 31%) with higher dysphagia scores in the mesh group. Current evidence does not support routine mesh use.

What are the risks of mesh in hiatal hernia repair?+

Mesh-related complications include dysphagia (consistently reported higher in mesh groups), mesh erosion into the esophagus or stomach, mesh contraction causing stricture, and difficulty with revision surgery. These complications, combined with the lack of long-term recurrence benefit, have led guidelines to recommend against routine mesh use.