Repair of the giant hiatal hernia

The repair of hiatal hernias, specifically giant hiatal hernias, is technically challenging and controversial. The approach to repair has shifted from thoracic to open abdominal to laparoscopic, which appears to be the current standard. High recurrence rates have been reported with laparoscopic procedures, but these are anatomic recurrences that are largely asymptomatic. Symptomatic recurrences with laparoscopic procedures appear to be similar to those seen with open abdominal procedures, but without the additional morbidity conferred by laparotomy. In the last decade, several studies have reported improved rates of recurrence using prosthetic meshes that have decreased even radiologic recurrence rates to below 5%. However, this has come at the price of rare but serious complications such as erosion and fibrosis. Mesh repair appears to be associated with a higher perioperative rate of dysphagia, which tends to resolve within the intervening months. Biologic meshes have been implemented in an attempt to obtain the buttressing effect of prosthetic meshes without the complications of erosion or infection. Early results have not proven biologic meshes to be as effective in reducing recurrence rates as prosthetic meshes, but there are currently no reports of erosion. Continued research is needed to elicit the optimal type of repair and mesh.