In an attempt to avoid the complications that can occur with prosthetic mesh, while still providing the benefits of reinforcement of the hiatal closure in reducing recurrence, biologic mesh has been used with increasing frequency over the last decade. Biologic mesh is designed to serve as a temporary extracellular matrix scaffold for native tissue ingrowth which theoretically results in stronger tissue through normal healing [22, 23]. A number of biologic hernia mesh implants have been developed: porcine small intestine submucosa, bovine pericardium, human cadaveric dermis, cross-linked porcine dermal collagen, and non cross-linked porcine epithelium, etc. Each of these commercial products has various “benefits” ascribed to them: longevity, workability, native growth factors to stimulate healing, etc, but the true clinical benefits of these elements have not been scientifically proven to date. Of all biologic implants, those derived from human cadaveric dermis and porcine small intestine submucosa have been the most widely studied. Although other implants have been used for reinforcement of hiatal closure, most have been reported only as single case reports.

Acellular dermal matrix has been subject of multiple studies that have shown a low rate of hiatal hernia recurrence [24, 25]. Ringley et al. prospectively studied 44 patients with hiatal hernias >5 cm, 22 who underwent hiatal hernia repair with primary closure, and 22 who underwent hiatal hernia repair with reinforcement of primary closure with onlay human acellular dermis. The authors found no difference in postoperative dysphagia in each group. They noted 9 % recurrence of hiatal hernia at 6-month follow-up in the primary closure group and none in the human acellular dermis group [26]. In a more recent retrospective study of a cohort of 52 consecutive patients who had primary closure reinforcement with onlay human acellular dermal matrix, the same group found a hernia recurrence rate of 3.8 %. In follow-up of 16 months, one patient underwent reoperation due to recurrent symptoms [25]. Similarly Diaz et al. [27] examined 46 patients with large hiatal hernias (>5 cm) who had laparoscopic hiatal hernia repair with reinforcement of crural closure and found a recurrence rate of 4.3 % at a mean follow-up of 3.6 months.

In 2003, we reported on nine patients who underwent laparoscopic repair of large paraesophageal hernias with porcine small intestinal submucosa (SIS) [28]. Eight patients had follow-up at a median of 8 months with barium esophagram and endoscopy. Only one patient had evidence of anatomical recurrence and one patient reported mild dysphagia that resolved after one endoscopic dilation. This led to a multicenter, prospective randomized trial which has recently reported long-term results [29]. In all, 108 patients with hiatal hernia >5 cm were enrolled and randomized to primary repair versus SIS-reinforcement of primary repair (57 patients with and 51 patients without biomesh reinforcement). At 6 months, 95 patients had an upper gastrointestinal study. There was a significant decrease in hernia recurrence in the biomesh group (9 %) and the primary closure group (24 %). Although initial results were promising with regards to hiatal hernia recurrence using biologic mesh reinforcement, long-term data showed that the benefit diminished over time [30] (Fig. 18.5). Seventy-two patients from the initial 108 were followed-up at a median follow-up of 58 months. Sixty patients underwent repeat upper gastrointestinal series (34 patients in the primary repair group and 26 patients in the biomesh group). There was a 59 % recurrence in the primary repair group compared to 54 % recurrence in the biomesh group and there were no reported cases of erosions, strictures, dysphagia, or other complications related to the biologic mesh. There was also not a significant difference in relevant symptom severity or quality of life scores between groups. Interestingly there were two reoperations for hiatal hernia recurrence in the primary repair group and none in the biomesh group. To date this is the only long-term randomized prospective clinical trial using a biologic mesh.

More recently, absorbable mesh has been studied in hiatal hernia repair. They presumably work by providing short-term structural reinforcement and by causing an inflammatory response during their resorption that results in a thicker scar. Parsak et al. [31] conducted a prospective randomized study with 75 patients who underwent LARS with polypropylene hiatal reinforcement and 75 who underwent polyglactin (Vicryl) mesh reinforcement. They showed that at a median follow-up of 38 months recurrence was similar between the polypropylene group and the absorbable mesh group: 5 and 4 %, respectively. These initial results are promising, however a major limitation of this study was that not all patients had objective studies to determine radiographic recurrence. Another problem is that, unlike recurrence with prosthetic mesh which occurs in less than 1 year, recurrence can occur much later with biologic and presumably absorbable meshes.

The best position and method of fixation of mesh remain poorly understood and there is no evidence to date to support one approach over another. The majority of practitioners perform primary closure and then reinforcement with an onlay mesh. This is obviously the only method possible with absorbable and biologic meshes. There are reports describing “bridging” techniques with synthetic mesh and there are even commercial meshes designed specifically to bridge (Fig. 18.6). In general, experts question (admittedly without evidence) the wisdom of placing mesh directly in contact with the esophagus. We describe below one mesh overlay technique using biologic mesh.

A standard laparoscopic set up is used. The patient is placed in a modified lithotomy or split-leg position with a beanbag allowing for steep reverse Trendelenburg position. We begin with the left upper quadrant port, placed just lateral to the midclavicular line at the costal margin. Pneumoperitoneum is obtained using Veress needle followed by placement of a 10 mm optical trocar. A 5 mm camera port is positioned at 10–12 cm from the costal margin in a line that is 2 3 cm to the left of the umbilicus. Two additional 5 mm ports are then placed, one in the right upper quadrant and the other at the left anterior axillary line at the level of the camera port. Finally, a Nathanson liver retractor is placed through a stab wound just to the left of midline high in the epigastrium and used to retract the left liver lobe. This can be substituted with a paddle retractor if the left lobe of the liver is large. The short gastric and retro gastric vessels are divided to the level of the left crus. Circumferential dissection of the hernia sac from the hiatus and mediastinal structures is then performed. The mediastinal dissection is carried proximal until there is at least 3 cm of intra-abdominal esophagus.

The sac is then everted over the GEJ and partially excised (to the left of the anterior vagus to avoid its transection). The hiatus is closed posteriorly with interrupted permanent sutures. The suture pattern can be interrupted, figure-of-8 or horizontal mattress sutures.

For reinforcement of these large defects—by nature repaired under tension—a U-configured biologic mesh is placed at the hiatus with the U base overlying the posterior hiatal closure. It is then sutured to the diaphragm with interrupted sutures or secured with fibrin glue to provide good contact between the SIS and diaphragm (Fig. 18.7a–d). A Nissen fundoplication of between 2.5 and 3 cm in length is created over a lighted 50–54 Fr Bougie. As the fundoplication is completed, it is positioned onto the esophagus and the top of the fundoplication is secured to the lateral aspects of the esophagus and to the left and the right crus. Additional sutures are placed to the undersurface of the diaphragm to secure the position of the fundoplication and prevent it from sliding. After the fundoplication, upper endoscopy is performed to examine the esophagus, discover accidental injuries, and thoroughly evaluate the fundoplication in terms of its shape, position, and tightness.

Swanstrom and colleagues described an alternative technique called the incorporated technique [32]. Using this method, the mesh implantation is performed simultaneously with the diaphragmatic closure using horizontal pledgeted sutures. The first suture, with pledget loaded, passes through the lower left side of the mesh then the left crus. The needle is passed through the hiatus and the right crus and finally through the back right side of the mesh. The needle is brought back out through the trocar and exchanged for the second needle of a double-armed heavy braided permanent suture. This needle is then run through the same sequence again. Once both needles are outside the trocar, they are passed though a second pledget and the mattress suture is secured. These steps are repeated for each suture until the closure is complete (usually 3 mattress sutures total) (Fig. 18.8a–f).