As far as the RCTs are concerned, Carlson etal. [30] reported the rst RCT ana­lyzing 31 patients with large PHH of 8cm or greater undergoing suture vs mesh cruroplasty. Their follow-up ranged from 12 to 36months. The author of this study demonstrated zero recurrence with mesh (PTFE) repair compared to 19% with suture only repair. Frantzides and colleagues [31] who used the same type of mesh in a larger group of patients (n=72) similarly reported a signicantly higher recur­rence rate for suture cruroplasty compared to prosthetic repair (22% vs 0% respec­tively) at a median follow-up of 2.5years [31]. Five of those eight recurrences needed reoperation with mesh repair, while the rest declined surgery. The hiatal defect in this study was also ≥8cm. Granderath etal. [32] published their RCT data on 100 patients who were subjected to suture vs mesh cruroplasty. They utilized gastroscopy, 24-h ambulatory pH study and esophagogram at 3 and 12months to evaluate their recurrence rate. Although a higher rate of recurrence (26%) was noted in the suture group compared to the mesh group (8%), the data regarding their out­come was not available and the follow up was short (12months). Two further RCTs [9, 41] showed comparable recurrence rates, 59% vs 54% [9] and 23% vs 21% [41] between the suture and mesh groups respectively, at 60 and 12months’ follow-up respectively. The last two RCTs investigated the role of biologic mesh vs suture crural repair [9, 41]. Oelschlagers et al.’s study demonstrated an increasing inci­dence of recurrence and diminishing durability of the repair with time, irrespective of the material used, although mesh related complications with biologic mesh were nil [9]. This trial reported a 9% rate of recurrent hiatal hernia in the biologic pros­thetic group compared to 24% in the suture cruroplasty group at 6months’ follow­up. However, at a median follow-up of 58months analyzing the same cohort of 72 patients, the recurrence rate in both groups was similar; 59% in the suture cruro­plasty group and 54% in the biologic prosthetic group. No statistical signicant difference was noted in terms of relevant symptoms or QOL issues between the two groups. No mesh related complications were seen with biologic mesh. The authors of this study concluded that the benet of biologic prosthesis in reducing hiatal her­nia recurrence diminishes at long-term follow-up. These authors emphasized the validity of their results based on the following facts; (1) the objective manner of detecting postoperative recurrence by a blinded third party i.e., radiologists and (2) the participation of experienced laparoscopic surgeons from high volume esopha­geal surgical centers. However, they conceded that strict criteria used to diagnose the recurrence may have overestimated the recurrence rate. Nonetheless, the authors of this study feel that although the biologic mesh, may not protect against recurrent hiatal hernias, it may reduce the risk of severe hernias resulting in fewer reoperations as evident in their study. They also felt that compared to non-absorbable mesh with its known complications such as erosion into adjacent structures e.g., esophagus or stomach which leads to severe dysphagia, the biologic mesh has no long-term nega­tive consequences. Other comparative studies investigating the role of these meshes in the last decade have shown no difference in the recurrence rate between suture and biological mesh groups [9, 33, 39–41].