Acellular dermal graft reinforcement at the hiatus.

The ideal technique to repair large hiatal and diaphragmatic defects remains controversial. Due to high recurrence rates with primary repair alone, attempts at crural reinforcement with various products has been investigated. Initial evaluation of synthetic mesh at the hiatus in retrospective studies led to the conclusion that there were too many serious complications with these products. The next step was to see how biologic grafts fared in this location. Beginning with porcine intestine submucosa in a laminated array and progressing through human and porcine acellular dermal matrices, multiple, retrospective studies looked at the efficacy and safety of these products. Unfortunately, most of these studies evaluated a small sample size with a relatively short follow-up period. The one study followed out to 5 years failed to show any benefit using the biologic (porcine intestinal submucosa) compared with the primary repair alone. Additional, prospective, randomized studies with ample numbers carried out for years will be necessary to see which biologic graft is not only safe but also successful in preventing recurrent herniations.