Management of recurrent hiatal hernia: a systematic review and meta-analysis comparing mesh versus no mesh reinforcement

Abstract Introduction Recurrent hiatal hernia (HH) is a significant challenge in surgical practice, with recurrence rates reported to range between 25% and 42%. This condition often requires redo surgeries, which are technically demanding and complex. While advancements in surgical techniques have improved outcomes, the optimal strategy for the surgical management of HH recurrence remains unclear. While mesh reinforcement is proposed to reduce recurrence, its use remains controversial due to potential complications. This systematic review and meta-analysis aim to evaluate whether redo-surgery for HH with cruroplasty using mesh reinforcement was superior to suture cruroplasty in terms of postoperative complications and mortal- ity. To our knowledge, there is no existing review on the topic using a systematic approach. Methods and procedures A comprehensive literature search of PubMed, Scopus, and Web of Science was conducted according to PRISMA 2020 guidelines. Studies evaluating postoperative outcomes of redo surgery for recurrent HH with and without mesh reinforcement were included. A random-based model was used in the meta-analysis to explore potential between-study heterogeneity. Odds ratios (OR) with 95% confidence intervals (CI) were calculated. The risk of bias was assessed with the Risk Of Bias In Non-randomized Studies - of Interventions (Version 2) ROBINS-I. Results A total of 14 studies with 1011 patients were included. No statistically significant difference was observed in post- operative complications (OR=0.58, 95% CI=0.32–1.04, p=0.07) or mortality (OR=0.41, 95% CI=0.08–1.98, p=0.27) between mesh-reinforced and non-reinforced cruroplasty. However, the results suggest a numerical tendency toward lower rates in the mesh group, which did not reach statistical significance. The funnel plots were symmetrical, suggesting no significant publication bias. The overall quality of evidence was moderate, with considerable heterogeneity among studies. Conclusion ThisreviewhighlightsthesheerlackofrobustdataonthebenefitofmeshplacementinHHrepairandthesignif- icant heterogeneity in the available literature. Although mesh reinforcement shows a potential trend toward better outcomes, it does not achieve statistical significance in reducing complications or mortality. New prospective, RCTs are necessary to better evaluate the benefits and risks of mesh placement.