The Choice of Primary Repair or Mesh Repair for Paraesophageal Hernia

A Decision Analysis Based on Utility Scores

Nadia M. Obeid, MD; Vic Velanovich, MD


Annals of Surgery. 2013;257(4):655-664. 

In This Article

Abstract and Introduction


Background: Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair.

Methods: A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment.

Results: Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small.

Conclusions: Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.


In the early 1990s, the first laparoscopic paraesophageal hernia (PEH) repairs were performed, and over the subsequent years, this approach has become the standard,[1] with good improvement in quality of life.[2] Since then, controversies have developed pertaining to whether observation or operation is the best approach for asymptomatic PEHs,[3] the frequency of and the need to intervene for the "short esophagus,"[4] whether open laparotomy/thoracotomy or laparoscopic operations provide a more durable repair,[5] the need for gastropexy or fundoplication,[6] and, last, whether the hiatal defect requires mesh or not for repair, and if so, what type of mesh.[7]

The use of mesh to repair PEH started in the open surgery era, but has grown increasingly popular as laparoscopic repair has become the standard. The rationale behind a mesh repair is that it would provide a "tension-free" repair analogous to mesh repair of inguinal or incisional hernias.[8–11] However, mesh PEH repairs have not become standardized, with variation in the type of mesh (broadly categorized into prosthetic or biological material), shape of mesh (strip, U-shape, or key-hole patterns), and fixation methods (suture or tacking device).[12] Reports then began to be published pertaining to mesh-related complications, the most serious of which were erosions of the mesh into the esophagus.[13–16] This lead to the popularization of biological mesh materials, with the rationale being that these would cause fewer mesh-related complications.[17] After initial enthusiasm, some have questioned the value of mesh PEH repairs.

Decision analysis is a method to explicitly account for all, or at least the most important, aspects of a decision to determine the most optimal choice.[18] This method requires identification of the possible consequences of the decision, the likelihood of these consequences occurring, and the impact of their occurrence. We hypothesized that this method would determine clear superiority of mesh repair or primary repair of PEHs.