Laparoscopic paraesophageal hernia repair with absorbable mesh: a systematic review

Background: Laparoscopic repair is the standard of care for patients with paraesophageal hernia (PEH). Different prosthetic materials have been proposed to bolster the hiatus thus theoretically minimizing the probability for hernia recurrence. The use of non-absorbable mesh has been reported however, their safety profile has been questioned because the noteworthy mesh-related complication rate. Opposite, absorbable mesh (synthetic and biologic) seems associated with mitigated mesh-related complications and comparable hernia recurrence in the short- and medium-term. Methods: PubMed, MEDLINE, EMBASE, Scopus, Google Scholar, and ClinicalTrials.gov were executed according to the PRISMA statement until May 2022. Primary endpoints were technical details and surgical outcomes of adult patients (>= 18 years old) that underwent laparoscopic PEH repair and crural reinforcement with absorbable mesh. The ROBINS-I tool was used to assess the methodological quality of included studies. Results: Thirty-nine studies (3,103 patients) were included. The age of the patient population ranged from 18 to 93 years old and 62.8% were females. Posterior cruroplasty was performed in all patients. U-shape (83.7%), circumferential (8.1%), keyhole (5.4%) and starburst (2.8%) mesh configuration were described. Different methods for mesh fixation (sutures vs. fibrin glue vs. absorbable tacks) were adopted while Nissen (75.1%) and Toupet (21.1%) fundoplication were mainly fashioned. The overall postoperative complication rate was 2.5%. Pulmonary and cardiac complication rates were 1.8% and 0.9%, respectively while in-hospital mortality was 0.2%. Postoperative follow-up ranged from 12 to 166 months. Mesh-related complication rate was 0.06% (esophageal stricture related to fibrosis). Hernia recurrence rate was 12.7% while re-do surgery was required in 1.9% of patients. Postoperative dysphagia rate was 5.1%. Discussion: Consensus concerning the optimal mesh material for crural buttressing is lacking. Given the potential for tissue ingrowth rather than encapsulation and reduced degree of perivisceral inflammation, absorbable meshes are mostly preferred over non-absorbable meshes. The use of absorbable mesh seems safe and effective with low overall and mesh-related complications, acceptable recurrence rate and low need for re-do surgery in the short/medium-term. Because heterogeneity related to different hernia characteristics, intraoperative technical variations (i.e., method for mesh fixation, etc.), definition of hernia recurrence and diverse follow-up, a conclusive evidence is still to be defined.