***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background / Aims : Primary repair of a large hiatal hernia is associated with a published recurrence rate of up to 10 % ; anecdotal rates even higher than this have been reported to the authors . The use of prosthetic material in the repair of other abdominal wall defects has often produced better results than primary repair . We wanted to compare laparoscopic primary repair of large hiatus hernias with laparoscopic primary repair reinforced with prosthetic . Methods : Thirty-one patients with symptomatic gastroesophageal reflux and a hiatal defect 8 cm or greater were r and omized to Nissen fundoplication with posterior cruroplasty ( n = 16 ) or Nissen cruroplasty , and onlay of polytetrafluoroethylene ( PTFE ) mesh ( n = 15 ) . All patients underwent preoperative esophagogastroduodenoscopy ( EGD ) and barium esophagography .  After posterior cruroplasty with interrupted nonabsorbable suture , the mesh reinforcement group had an onlay of PTFE placed around the hiatus . A radial slit with 3 cm ‘ keyhole ’ ( to accommo date the esophagus ) was cut into the PTFE . The prosthetic was stapled to the diaphragm , and the two leaves of the slit were stapled to each other . All patients underwent EGD at 3 months and all had esophagrams every 6 months postoperatively . Follow-up ranged from 12 to 36 months . Results : Length of hospital stay was equal in both groups ( 2 days ) . The average cost to the patient with PTFE was USD 1,050 higher than to the patient with primary repair . There were 2 complications ( 1 pneumonia , 1 urinary retention ) in the PTFE group , and 1 complication ( pneumothorax ) in the primary repair group . There were 3 recurrences ( 18.8 % ) in the primary group ( p = 0.08 , χ2 test ) . Conclusion : The use of PFTE reinforcement for primary repair of large hiatal hernias may result in a lower rate of recurrent herniation compared to primary repair alone BACKGROUND Recent reports suggest that when laparoscopy is used to repair paraesophageal hernias recurrence rates reach 20 % to 40 % . Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in esophageal injury . We hypothesized that reinforcement of the hiatal closure with small intestine submucosa ( SIS ) mesh , in some unusually large hernias , might reduce recurrence rates without causing injury to the esophagus . METHODS From January 2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic approach .  In 9 of the largest hernias ( one type II and 8 type III , of which 1 was recurrent ) the repair was reinforced with SIS mesh ( Surgisis , Cook Surgical ) and represent the subjects of this study .  Nissen fundoplication with gastropexy was performed in all patients . Clinical follow-up ranged from 3 to 16 months ( median 8) . Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8 months ( median 2 ) postoperatively . RESULTS The presenting symptoms were postpr and ial pain/fullness ( 9 of 9 ) , heartburn ( 4 of 9 ) , anemia ( 4 of 9 ) , dysphagia ( 3 of 9 ) , regurgitation ( 3 of 9 ) , and chest pain ( 3 of 9 ) . One patient died of a hemorrhagic stroke within 30 days of the operation . Postoperatively , presenting symptoms resolved ( 83 % ) or improved ( 17 % ) in each of the remaining 8 patients . One patient required endoscopic dilation for mild dysphagia .  Seven of 8 patients had a normal barium esophagram without evidence of hernia . One morbidly obese ( body mass index = 47 ) patient had a small ( 2 cm ) sliding hiatal hernia postoperatively . There were no other complications , and specifically no perforations or mesh erosions . CONCLUSIONS These observations suggest that the use of SIS in the repair of paraesophageal hernias is safe and may reduce recurrence . Longer follow-up and a r and omized study are needed to vali date these results HYPOTHESIS Large hiatal hernias are prone to disruption , result ing in reherniation , when repaired with simple cruroplasty . The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias . DESIGN Prospect i ve , r and omized controlled trial . SETTING University-affiliated private hospital . PATIENTS Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter . INTERVENTION Nissen fundoplication with posterior cruroplasty ( n = 36 ) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene ( PTFE ) mesh ( n = 36 ) . MAIN OUTCOME MEASURES Recurrences , complications , hospital stay , operative time , and cost . RESULTS Patients in both groups had similar hospital stays , but the PTFE group had a longer operative time . The cost of the repair was $ 960 + /- $ 70 more in the group with the prosthesis . Complications were minor and similar in both groups . There were 8 hernia recurrences ( 22 % ) in the primary repair group and none in the PTFE group ( P<.006 ) . CONCLUSION The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences Abstract Background : Several studies have shown that large hiatal hernias are associated with a high recurrence rate . Despite the problem of recurrence , the technique of hiatal herniorrhaphy has not changed appreciably since its inception . In this 3-year study we have evaluated laparoscopic hiatal hernia repair in individuals with a hernia defect greater than 8 cm in diameter . Methods : A series of 35 patients with sliding or paraesophageal hiatal hernias was prospect ively r and omized to hiatal hernia repair with ( n= 17 ) or without ( n= 18 ) polytetrafluoroethylene ( PTFE ) . All patients had an endoscopic and radiographic diagnosis of large hiatal hernia . Both repairs were performed by using interrupted stitches to approximate the crurae . In the group r and omized to repair with prosthesis , PTFE mesh with a 3-cm ` ` keyhole ' ' was positioned around the gastroesophageal junction with the esophagus through the keyhole . The PTFE was stapled to the diaphragm and crura with a hernia stapler . Results : Patients were followed with EGD and esophagogram at 3 months postoperatively , and with esophagogram every 6 months thereafter . Individuals with PTFE had a longer operation time , but the 2-day hospital stay was the same in both groups . The cost of the repair was $ 1050 ± $ 135 more in the group with the prosthesis . There were two complications ( 1 pneumonia , 1 urinary retention ) in the group repaired with PTFE and one complication ( pneumothorax ) in the group without prosthesis . The group without PTFE was notable for three ( 16.7 % ) recurrences within the first 6 months of surgery . Conclusion : On the basis of these preliminary results it appears that repair with PTFE may confer an advantage , with lower rates of recurrence in patients with large hiatal hernia defects Background The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison with primary suture repair . However , there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion . The aim of this study was to evaluate a lightweight polypropylene mesh ( TiMesh ) repair of hiatal hernias with particular reference to intraluminal erosion . Methods Data were collected prospect ively on 18 consecutive patients undergoing elective laparoscopic repair of a large hiatal hernia with the use of TiMesh between November 2004 and December 2005 .  Quality of life and symptom analysis was performed using QOLRAD question naires preoperatively and postoperatively after 6 weeks , 6 months , 1 year and 2 years . Barium studies were performed preoperatively and 2 years postoperatively to assess hernia recurrence . After 2 years , oesophagogastric endoscopy was performed to assess signs of  mesh-related complications . Results All operations were completed laparoscopically . There was no 30-day mortality and median hospital stay was 2.8 days ( range 2–13 days ) . Complications occurred in two patients ( 11 % ) , both of whom were treated without residual disability . Two years after hiatal hernia repair , there was significant improvement in quality -of-life scores ( QOLRAD 5.79 , p < 0.001 ) . There was no difference between pre- and postoperative dysphagia scores . No signs of stricture formation or prosthetic erosion were identified during endoscopic follow-up . One patient had a small ( 2 cm ) sliding hiatal hernia demonstrated by barium studies , which was asymptomatic . Conclusions Laparoscopic reinforcement of primary hiatal closure with TiMesh leads to a durable repair in patients with large hiatal hernias . Endoscopic follow-up did not show any signs of mesh-related complications after prosthetic reinforcement of the crural repair . Our preliminary results suggest that it is safe to proceed with this lightweight polypropylene mesh for reinforcement of the hiatal repair Background The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison to primary suture repair . However , there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion . The aim of this study was to critically evaluate a novel mesh ( DualMesh ) repair of hiatal hernias with particular reference to intraluminal erosion . Method Medical records of 19 patients who underwent laparoscopic hiatal hernia repair with DualMesh reinforcement of the crural closure were review ed from a prospect ively collected data base .  Quality of life and symptom analysis was performed using quality of life in reflux and dyspepsia ( QOLRAD ) question naires pre- and postoperatively after 6 weeks , 6 months , 1 year and 2 years . Barium studies were performed on patients pre-operatively and two years postoperatively to assess hernia recurrence . After 2 years , oesophagogastric endoscopy was performed to assess signs of erosion . Results Mean patient age was 70.5 years ( range 49–85 years ) . Two years after hiatal hernia repair , there was significant improvement in quality -of-life scores ( QOLRAD : p < 0.001 ) . Follow-up barium studies performed at 31.3 months ( range 29–40 months ) after surgery showed moderate recurrent hernias ( > 4 cm ) in 1/14 patients ( 7 % ) . Endoscopies performed at 34.4 months ( range 28–41 months ) after surgery did not show any signs of prosthetic erosion . Conclusion Laparoscopic reinforcement of primary hiatal closure with DualMesh leads to a durable repair in patients with large hiatal hernias . Long-term endoscopic follow-up did not show any signs of mesh erosion after prosthetic reinforcement of the crural repair HYPOTHESIS Laparoscopic repair of  large hiatal hernia is an appropriate management strategy . DESIGN A prospect i ve patient series . SETTING A university teaching hospital . PATIENTS All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1 , 1992 , and September 30 , 1998 . INTERVENTIONS Two operative strategies were used for laparoscopic repair : the first , which was used until early 1996 , entailed initial esophageal dissection while leaving the sac in the mediastinum . The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus . MAIN OUTCOME MEASURES Successful completion of the procedure using a laparoscopic technique , postoperative complication rate , reoperation rate , and clinical outcome . RESULTS Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods . The median age was 63 years ( range , 30 - 91 years ) , and 45 patients ( 52 % ) were women . There were 30 sliding , 10 rolling , and 46 mixed hiatal hernias .  Operating times ranged from 48 to 240 minutes ( median , 90 minutes ) , and 20 procedures ( 23 % ) were converted to an open operation . Conversion was significantly more common in the first half of our experience ( 16 [ 40 % ] of 40 patients vs 4 [ 9 % ] of 46 patients ) before the operative strategy was changed . Esophageal-lengthening procedures were not carried out for any patient . At follow-up of a median of 2 years , 1 patient has moderate dysphagia , 4 patients have reflux symptoms , and 1 patient has undergone further surgery for a recurrent paraesophageal hernia . An overall satisfactory outcome was achieved in 81 patients ( 94 % ) . CONCLUSIONS Large hiatal hernias can be treated effectively laparoscopically . Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus , and we think changing to this 
    Output:
    
Conclusions The use of mesh in the repair of large hiatal hernias is promising with respect to the reduction of anatomical recurrences .