The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients ≥18 years of age who underwent LHHR between the years of 2010 and 2017. Current Procedural Terminology (CPT) codes were used to separate eligible patients into two cohorts: LHHR with mesh (CPT 43282: “Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh”) and LHHR without mesh (CPT 43281: “Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh”). For the purposes of this study, the terms “hiatal hernia” and “paraesophageal hernia” were used interchangeably; a patient with any of the International Classification of Disease 9th and 10th edition (ICD-9 and -10) codes listed in Table 1 was considered to have a hiatal hernia. All study protocols and procedures were reviewed by the Institutional Review Board at Western Michigan University Homer Stryker MD School of Medicine.

Primary study outcomes included rates of morbidity (minor, serious, and overall) and mortality at 30-days post-procedure. For the purposes of this study, minor morbidity was defined as documentation of ≥1 minor ACS-NSQIP complications (pneumonia, superficial or deep incisional surgical site infection [SSI], unplanned intubation, urinary tract infection, or deep vein thrombosis. Serious morbidity was defined as documentation of ≥1 major ACS-NSQIP complication(s) (organ space SSI, wound disruption, cerebrovascular accident, cardiac arrest requiring CPR, myocardial infarction, pulmonary embolism, mechanical ventilation for ≥48 h, acute renal failure, progressive renal insufficiency, transfusion of >4 units packed red blood cells, sepsis, and septic shock). Overall morbidity was defined as documentation of ≥1 source of minor or serious morbidity. These classifications are consistent with those employed by previous studies involving the ACS-NSQIP database (16). Secondary outcomes included mean total LOS, operative time, and rates of reoperation and hospital readmission.

Descriptive statistics were used to summarize patient demographics, preoperative risk factors, and postoperative outcomes. Continuous variables were analyzed using Student's t-test or the Mann–Whitney U test and presented as mean (SD) or median (IQR) as appropriate. Categorical variables are presented by frequency (n) and percent (%) and analyzed using the Chi-Squared or Fisher Exact tests as appropriate. Statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS software (IBM SPSS Statistics for Windows, Version 27.0, IBM Corp.).

A total of 24,488 patients were identified, of which 9,170 (37.4%) underwent LHHR with mesh and 15,318 (62.6%) underwent LHHR without mesh. 17,596 (72%) of the identified patients were female. Demographic characteristics (sex and race) were similar between the groups. However, patients who underwent LHHR with mesh were more likely to have hypertension (52.4% vs. 48.8%, p < .001) and dyspnea (13.6% vs. 11.7%, p < .001). Conversely, patients who had LHHR without mesh were younger (60.2 years vs. 63.2 years old, p < .001) and more likely to have diabetes (10.0% vs. 8.5%, p < .001). Notably, patients over the age of 65 were significantly more likely to have repair with mesh (47% vs. 39%, p < .001). Information regarding additional demographics and comorbidities can be found in Table 2.

There were no significant differences between the groups in mortality (0.6% vs. 0.6%, p = .990), minor morbidity (4.3% vs. 4.1%, p = .561), serious morbidity (3.8% vs. 3.5%, p = .135), or overall morbidity (6.4% vs. 6.2%, p = .468). Mesh use was associated with significantly more myocardial infarction (0.2% vs. 0.4%, p = .006), albeit the total incidence was quite low. Reoperation rates did not differ between the groups (2.6% vs. 2.6%, p = .945). Repair with mesh was associated with increased readmission (6.6% vs. 5.8%, p = .013), increased median (IQR) operative time [147 (108, 197) vs. 130 (91,175) minutes, p < .001], and increased LOS (3.0 vs. 2.9 days, p = .002). The complete analysis can be found in Table 3.

In our experience, the choice to employ mesh during LHHR is driven largely by surgeon preference—some surgeons routinely use mesh, others reserve it for specific patient groups, while some avoid it altogether. Due to this variability in practice, several studies have examined rates of recurrence for mesh vs. suture-only repair, with some stratifying based on defect size. In the short-term, it appears that mesh does not significantly impact recurrence rates, regardless of size (23, 24). However, in the longer-term, the evidence is less clear—some studies report lower recurrence rates when mesh is employed, while others have found no significant differences (25). It must be noted that many patients display radiological evidence of recurrence but remain asymptomatic, raising questions regarding the clinical utility of such findings (26). Patient-centered outcomes, mainly quality of life, are another factor to consider. Mesh use appears to be associated with less reflux symptoms in the year following surgery, but many patients report worsening dysphagia postoperatively (27). Interestingly, patients who undergo repair with biological mesh tend to score higher on short-term quality of indices, despite higher rates of dysphagia (28).

Given conflicting evidence regarding the impact of mesh on HH recurrence and quality of life, the potential for mesh-related complications must be considered. Therefore, our results may offer valuable context to inform clinical decision-making. Importantly, our study suggests that mesh placement offers a comparable safety profile relative to suture cruroplasty. However, we observed a notable difference in operative time, with mesh placement accounting for an additional 24 min in the operating room. Although this may appear to be somewhat inconsequential, the additional minutes can result in sizable direct and indirect costs for the payer and may also contribute to strain on healthcare resources (29, 30). Such costs accrue in addition to the substantial costs of the mesh deployed during the operation (31). Moreover, mesh placement was associated with increased hospital readmission—an event that correlates with poorer health outcomes, has negative impacts on quality of life, and may strain healthcare resources (32, 33). As studies evaluating the efficacy of mesh repair remain equivocal, and mesh use should be used at the discretion of the surgeon (14), our findings provide important context to consider.

Our study has some limitations. First, retrospective studies come with inherent limitations. One such limitation is potential confounding. For this reason, we assessed a multitude of comorbidities to identify possible confounds. Although information necessary to reach a definitive conclusion is not available in the ACS-NSQIP database, differing rates of COPD and hypertension may have contributed to higher rates of readmission in the mesh-reinforced group. Additionally, analysis of large existing databases comes with a risk of selection bias and coding errors. However, the significant diversity of hospitals included, and the intensive methodology of data collection utilized by the ACS-NSQIP database helps mitigate these risks. Second, the ACS-NSQIP database only tracks 30-day outcomes; therefore, longer-term sources of morbidity or mortality could be missed. Additionally, despite having more than 270 variables in the ACS-NSQIP database, these variables are global (i.e., applied to many surgical specialties and are not procedure or diagnosis-specific); therefore, information regarding the size of HH, whether primary or recurrent, and the specific mesh or reinforcement material used were not available for analysis. Over the eight years included in this study, the reason for readmission was not consistently recorded for all years in the ACS-NSQIP database. However, based on our observations, most readmissions were related to minor post-operative complications, such as UTI or SSI—as outlined in Table 3. Third, practical downstream consequences could not be assessed—such as potential economic strain for patients given the additional cost of mesh material, operating room time, and readmission. Fourth, although postoperative quality of life (QOL) is an important factor to consider, the ACS-NSQIP database does not currently include QOL metrics. Despite these limitations, this study's large size (in terms of patients, surgeons, and hospitals) provides a diverse sample that is more generalizable to the American population at large, relative to many other retrospective studies.