Barbed Sutures at the Hiatus: What’s the Evidence?

Background: Barbed sutures enable knotless, continuous cruroplasty and are increasingly used in hiatal and paraesophageal hernia repairs. Despite widespread adoption, outcome data specific to the hiatus are limited and diaphragmatic application remains off-label. Methods: A systematic search of PubMed and MEDLINE (inception–August 2025) identified adult hiatal/paraesophageal hernia repairs using barbed sutures. Data on operative approach, mesh use, operative time, recurrence, and perioperative outcomes were extracted. The FDA MAUDE database (2010 to 2025) was reviewed for device-related events. Results: Five studies (n=741) met the inclusion criteria. In laparoscopic comparisons, barbed sutures shortened per-stitch closure time compared with interrupted silk, although total closure time was not significantly different. In pooled analysis of 4 comparative studies, the weighted mean difference in operative time was +12.8 minutes (95% CI: –4.3 to 29.8; P =0.14; I ²=40%). Individual series demonstrated variable findings: operative time increased with mesh reinforcement but not when mesh was avoided ( P =0.45). One study reported that barbed cruroplasty with biosynthetic mesh reinforcement significantly reduced ≥1-year anatomic recurrence (24.7% vs. 44.9%; risk difference –20.3%, 95% CI: –33.7 to –7.0) and symptomatic recurrence (17.2% vs. 42.2%, P =0.003) compared with barbed suture-only repair. Postmarket surveillance analysis of the FDA MAUDE database (2010 to 2025) identified only 2 hiatal-specific adverse events associated with barbed sutures, although underreporting is likely. Conclusions: Barbed sutures for cruroplasty appear time-efficient and may lower recurrence when combined with mesh in larger hernias. However, current evidence is sparse, heterogeneous, and based largely on retrospective series. Given the off-label nature of diaphragmatic use, prospective studies with standardized recurrence definitions are needed to clarify safety and long-term efficacy.