Mesh-reinforced cruroplasty for type III-IV hiatus hernia repair: a single-center experience using the Patient-Tailored Algorithm

Aim: Laparoscopic hiatus hernia (HH) repair with cruroplasty is an effective treatment for symptomatic patients with type III-IV HH. Various techniques have been described for posterior cruroplasty, ranging from simple suture (SS) repair to suture reinforced with mesh. Mesh-buttressed (MB) cruroplasty aims to reduce HH recurrence, but there is no consensus on indications for mesh placement, mesh type, fixation method, or materials. This study aimed to assess the medium-term effectiveness of MB cruroplasty guided by the Patient-Tailored Algorithm (PTA) in laparoscopic repair of type III-IV HH. Methods: We conducted a single-center, retrospective observational study from November 2019 to April 2023, including patients with type III-IV HH. The institutional PTA, based on intraoperative measurable parameters (HH type, hiatus diastasis, pillars trophism, and redo surgery), was utilized to guide the decision-making process. If the PTA score exceeded 5, MB cruroplasty using a 10 × 7 cm keyhole-shaped Phasix-ST mesh was performed. The primary outcome was HH recurrence, defined as a combination of symptoms and anatomical gastric migration > 2 cm above the diaphragm. Univariate and bivariate analyses were performed. Statistical significance was set at P-value < 0.05. Results: Seventy-four patients with a minimum follow-up of 12 months were included. The median age was 66 years and 69% were female. The median follow-up was 38 months (range 12-98). MB cruroplasty was performed in 37 patients (50%). HH recurrence occurred in 7 patients (9.5%), with a clinical trend toward higher recurrence after SS compared with MB (10.8% vs. 8.1%). Postoperative quality of life, measured with the disease-specific GERD-HRQL, improved significantly compared to baseline (20 vs. 3, P = 0.004). In the MB group, both GERD-HRQL and Reflux Symptom Index (RSI) scores improved significantly compared to SS (GERD-HRQL: 2 vs. 7, P = 0.048; RSI: 3 vs. 10, P = 0.003). Trends toward improved SF-36 scores and reduced postoperative proton pump inhibitor (PPI) use were also observed. Conclusion: MB cruroplasty is associated with favorable medium-term outcomes, including reduced HH recurrence, improved quality of life, and decreased daily postoperative PPI use in patients with type III-IV HH. The PTA provides a simple, reproducible intraoperative strategy for guiding cruroplasty and standardizing surgical decision making in type III-IV HH repair.