To systematically evaluate the efficacy and safety of mesh (synthetic, biological or absorbable) reinforcement versus suture-only repair in the surgical treatment of hiatal hernia (HH).

A comprehensive literature search was conducted in PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, CBMdisc and VIP Chinese Journal Service Platform from inception to September 10, 2025 for randomized controlled trials (RCTs) comparing mesh-augmented HH repair with suture-only repair. After screened studies, data were extracted and assessed the risk of bias using the Cochrane RoB 2 tool. Meta-analysis was performed using RevMan 5.4.1 software. The primary outcome was radiologically or endoscopically confirmed anatomical recurrence. Secondary outcomes included incidence of dysphagia, reoperation rate, intraoperative complications, et al. Pooled risk ratios (RR) or mean differences (MD) with 95% confidence intervals (CI) were calculated using fixed-effect or random-effects models. Pre-specified subgroup analyses were conducted based on mesh material (absorbable or non-absorbable).

A total of 10 publications reporting outcomes from 8 RCTs follow-up were included, involving 768 patients. The mesh group consisted of 421 patients, while the suture group 347 patients. Regarding the reduction of postoperative anatomical recurrence rates, eight RCTs reported short-term (<1 year) recurrence. The initial meta-analysis indicated moderate heterogeneity among studies (I²=57%, P=0.02). Under a random-effects model, the mesh group demonstrated significant reduction in short-term recurrence risk (pooled OR=0.41, 95% CI: 0.18-0.92, P=0.03). Three RCTs reported mid- to long-term anatomical recurrence rates (follow-up >3 years), involving 215 patients in the mesh group and 211 in the suture group. No heterogeneity was observed among these studies (I²=0, P=0.77). A subgroup analysis based on mesh absorbability showed no significant difference between absorbable and non-absorbable meshes in the effect of reducing short-term recurrence (P=0.45). There was no statistically significant difference in hospital stay length between the two groups (P=0.485). Due to significant heterogeneity in data reporting formats, no quantitative pooled analysis was performed for this outcome.

In the surgical treatment of HH, the benefits of mesh reinforcement exhibit clear material-dependency and time-dependency. Non-absorbable synthetic mesh significantly reduces short-term recurrence risk, whereas the efficacy of absorbable biological mesh remains unconfirmed. Furthermore, evidence regarding the long-term durability of mesh is insufficient. Future high-quality RCTs with extended follow-up are required to validate the long-term outcomes of different mesh types.