The incidence of hiatal hernia increases with age, manifesting symptoms of heartburn, dysphagia, and chest pain. Laparoscopic hiatal hernia repair is the preferred treatment when surgical intervention is required [1]. However, the recurrence rate after laparoscopic hiatal hernia repair could range between 1.2% and 66% in patients with giant type III or IV hernias [2]. To reduce the rate of recurrence, mesh reinforcement is often recommended for large or recurrent hiatal hernias. However, mesh erosion and migration into the esophagogastric (EG) lumen after hiatal hernia repair have been reported. Herein, we describe a rare case in which proximal gastrectomy with mesh removal was performed to resolve mesh migration through the EG junction after laparoscopic hiatal hernia repair.

A 65-year-old woman presented with a 1-year history of dysphagia. The patient experienced intermittent abdominal pain, located in the epigastric area. Laboratory findings were within normal range. The patient had a history of hypertension, hyperlipidemia, and stroke. Abdominal computed tomography revealed a huge type IV esophageal hiatal hernia, through which the stomach extended into the thoracic cage (Fig. 1). On esophagogastroduodenoscopy (EGD), the stomach herniated through the diaphragm into the chest cavity. An endoscopic approach to the pylorus was difficult due to gastric torsion. No signs of stomach or bowel strangulation were detected. An upper gastrointestinal series (UGI) showed no definite obstruction of contrast passage. The patient experienced sustained dysphagia. Therefore, we performed laparoscopic hiatal hernia repair. Intraoperatively, the esophagus was too short to reach the subdiaphragm. We performed Collis gastroplasty to correct the shortened esophagus after hernial sac mobilization. The diaphragmatic relaxing incision on primary closure of the hiatal defect was not performed due to tolerable pliability of the crura. After performing tension-free fundoplication and reinforced crural repair, a 10 × 15 cm-sized, keyhole-shaped composite mesh with Ethibond 2-0 suture fixation (Ethicon) was placed (Fig. 2). The patient had uneventful postoperative recovery and was discharged home. After 6 months, the patient presented to our institution with dysphagia and intermittent vomiting. EGD showed that the mesh material migrated into the EG junction (Fig. 3). Additionally, the UGI showed an obstructive pattern at the EG junction with luminal distention at the distal esophagus (Fig. 4). We attempted to remove the mesh material endoscopically but failed. Thereafter, we performed a proximal gastrectomy with double-tract reconstruction, including mesh removal (Fig. 5). In the operative field, there was no evidence of hiatal hernia recurrence. The patient had an uneventful postoperative recovery and was discharged without any complications on the 8th day. Postoperative UGI and EGD were within normal range.

Figure 1. Abdominal computed tomography scan reveals a huge type IV esophageal hiatal hernia whereby the stomach is herniated into the thoracic cage.

Figure 2. Operative field after fundoplication and Collis gastroplasty with mesh repair.

Figure 3. Esophagogastroduodenoscopy showing the mesh material that is migrated into the esophagogastric junction.

Figure 4. Upper gastrointestinal series shows the obstructive pattern on the esophagogastric junction with luminal distention at the distal esophagus.

Figure 5. Resected specimen. The proximal part of the stomach and mesh migrated through the esophagogastric junction.

Most hiatal hernias are asymptomatic and incidentally diagnosed. However, in the case of a giant hiatal hernia, various symptoms such as heartburn, dysphagia, chest pain, and shortness of breath may appear. Surgery is usually considered when there is no resolution of gastroesophageal reflux symptoms despite medical management, or upon detection of a giant symptomatic hiatal hernia, such as a gastric outlet obstruction or strangulation.

Laparoscopic hiatal hernia repair is as effective as open repair and is a preferred approach. To reduce recurrence, mesh reinforcement has been recommended for large or recurrent hiatal hernias. Clinical studies have reported that the use of polytetrafluoroethylene (PTFE) reinforcement may result in a lower rate of recurrent herniation compared to primary closure alone [1]. The use of mesh for large hiatal hernia repairs leads to a decreased short-term recurrence rate. However, there is insufficient evidence to support long-term benefits. Mesh-related complications are rare, but if present, they may be disastrous, especially in cases of erosion, esophageal stenosis, and luminal migration through the esophagogastric junction as in this case. The exact basis for these complications remains unclear. Therefore, there have been trials on the type of mesh, fixation method, and other surgical techniques.

The most commonly used synthetic mesh materials are polypropylene, PTFE, or dual meshes. To prevent complications related to synthetic mesh, biologic mesh has been considered for hiatal hernia repair. A concern regarding biologic mesh is the risk of recurrence due to its weaker strength compared to synthetic materials. However, a few recent studies have shown that biological prostheses provide reliable outcomes for repairing hiatal hernias [3].

Another issue regarding hiatal hernia repair is the method of fixing the prosthesis after crural closure. Various techniques, such as adhesive, tacks, and sutures, are used to prevent complications uch as mesh migration. The application of tacks at hiatus has been reported to cause serious complications, such as cardiac tamponade and mortality. Therefore, they should be carefully placed low on the left crus or anteriorly near the apex of the crura. As a result, both biological and chemical adhesives, such as glue, might be effective alternative methods of mesh fixation with sutures in hernia repair, despite the drawbacks of expensive costs and allergenic properties.

Above all, surgical techniques could play a significant role in preventing hernia recurrence or complications. Diaphragmatic defects should be closed, if possible, and it is important to keep a proper distance between the mesh and esophagus without serosa. This is due to the potential mesh shrinkage of up to 50% of its original size and the risk of hiatal hernia recurrence, where the stomach slips above the diaphragm. Keeping a proper distance between the mesh and the esophagus can help prevent this complication. Antonino et al. [4] suggested that it is necessary to maintain a distance of 1 cm between the mesh and the esophageal wall. This positioning helps prevent compressive or erosive events from occurring to the organ. Braghetto et al. [5] also reported a preventive measure in which the hernia sac was mobilized to the EG junction to cover the onlay mesh, thereby preventing direct contact between the mesh and esophagus and minimizing the potential for erosion or migration. Additionally, the configuration of the mesh may play an important role in the success of hernia repair. There are different shapes (U-shape, A-shape, C-shape, keyhole-shape) of mesh and they can be placed in a circular, posterior, or anterior fashion for hiatal reinforcement. Keville et al. [6] suggested that the keyhole pattern mesh was not associated with a higher complication rate compared to the U-shape pattern, and it was also accompanied by fewer recurrences. However, other reports have shown that the keyhole mesh with circular pattern placement has resulted in a higher incidence of dysphagia and erosion. As a result, the U-shaped onlay patch has become the preferred configuration. Chen et al. [7] also switched to a U-shaped composite mesh because the mesh migrated into the esophagus after using a keyhole-shaped mesh, which presents a strong argument against circular positioning. Another study showed that circular implantation of meshes around the esophagus could lead to a high rate of mesh migration. However, standard methods to ameliorate this complication have yet to be determined and future research should focus on improving the surgical techniques and biomaterials in order to achieve optimal outcomes.

Sánchez-Pernaute et al. [8] reported that six out of 122 patients (4.9%) who underwent mesh hiatoplasty showed mesh erosion (mean time from surgery to diagnosis of erosion, 42 months) and dysphagia as the most frequent presenting symptom similar to our case. Other reports have described the postoperative duration of complications as highly variable, ranging between 1 week and 9 years. Mesh complications at the EG junction generally lead to poor oral intake and exaggerated general conditions. Therefore, keen attention at symptom onset, early diagnosis, and appropriate treatment are factors directly related to postoperative prognosis.

Regarding mesh-related complications, endoscopic retrieval might be the first-line method to resolve mesh-related complications. However, it is difficult to completely remove the mesh. Therefore, surgical intervention is frequently required, except for totally asymptomatic patients [3]. Yatabe et al. [9] reported that additional surgical intervention was necessary in 68% of cases, and the mesh was removed endoscopically in 21% of cases. Esophagectomy, total gastrectomy, or partial gastrectomy are needed for complete mesh removal. In our case, proximal gastrectomy was performed after endoscopic approach failure.

In patients with a shortened esophagus, Collis gastroplasty provides a means to lessen tension on the repair. The use of adjunctive techniques, including Collis gastroplasty and mesh reinforcement, remains controversial. The risk of esophageal or stomach perforation during laparoscopic Collis gastroplasty ranges from 2% to 7.5% [10]. Therefore, Collis gastroplasty with mesh reinforcement should be used with caution due to the potential risk of mesh migration.

In conclusion, mesh-associated complications, such as erosion or migration, after laparoscopic hiatal hernia should be considered as they may be more common than previously reported and currently underscored in clinical practice. Additionally, in mesh applications, symptoms of mesh-related complications, such as dysphagia, should be carefully monitored for early detection. Although some cases may be managed conservatively or endoscopically, surgical interventions such as gastric or esophageal resection may be frequently necessary for mesh removal.

Ethical statements

This research was approved by the Institutional Review Board of Eulji University (No. 2023-10-009) regarding ethical issues, including consent from participant. And we obtained informed consent from the patient for the publication of images of the patient’s body parts.

Authors’ contributions

Conceptualization: MSL

Data curation: DKL, HYH

Formal analysis: DKL

Investigation: DKL, HYH, JHK

Methodology: MSL, JHK

Visualization: HYH

Writing–original draft: MSL

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.

Data availability

The data presented in this study are available on request from the corresponding author.