Background
Laparoscopic antireflux surgery is a well-established treatment option for gastroesophageal reflux disease (GERD), especially when symptoms persist despite long-term medication or when patients prefer a surgical solution. In many patients, surgery can provide durable relief from reflux, heartburn, and regurgitation, while reducing reliance on proton pump inhibitors and other acid-suppressing drugs.
However, repairing the hiatus, the opening in the diaphragm through which the esophagus passes, can be challenging. This is especially true in two situations: redo surgery after a failed previous hiatal repair, and operations for giant hiatal hernias, including large paraesophageal hernias and upside-down stomach cases. In these settings, the tissues are often scarred, shortened, or under significant tension. Excess tension on the crural sutures is one of the main reasons repairs fail over time.
In routine practice, some surgeons use mesh reinforcement at the hiatus in an attempt to lower recurrence risk. But long-term studies have not consistently shown that mesh prevents hernia recurrence, and mesh use may bring its own complications. For that reason, tension-reduction strategies that help achieve a more natural, durable closure remain of considerable interest.
One such strategy is the use of relaxing incisions in the diaphragm lateral to the hiatus. These cuts are intended to reduce tension on the repair by allowing the crura to come together more easily. The concept is simple: if the tissues can be approximated without being pulled tightly, the repair may be more stable and less likely to recur.
Study Objective
This study examined whether a modified technique using lateral relaxing diaphragmatic incisions could be safely and practically added to difficult hiatal repairs in patients undergoing redo surgery or surgery for giant hiatal hernia. The investigators also wanted to know whether the operation improved symptoms such as heartburn and dysphagia, which can serve as patient-centered indicators of recurrence or failure.
Methods
Patients with symptomatic recurrent hiatal hernia or giant hiatal hernia were treated with standard laparoscopic surgery using a five-port technique. The operation was supplemented by tension-reducing relaxing incisions in selected cases.
Most patients underwent bilateral relaxing incisions in the diaphragm, placed lateral to the hiatus before the hiatal closure was completed. The purpose was to facilitate tension-free approximation of the crura. The surgeons avoided opening the pleura in order to reduce the risk of capnothorax, a condition in which carbon dioxide used during laparoscopy accumulates in the chest cavity and can impair breathing and surgical visibility.
The analysis focused on feasibility and applicability of this modified technique, which has not yet become widely adopted in upper gastrointestinal surgery across Europe. Patient outcomes were collected from a prospectively maintained laparoscopic antireflux surgery database. Relevant measures included postoperative dysphagia, heartburn, and current use of proton pump inhibitors.
Patient Population
Between September 2019 and October 2022, 84 patients underwent surgery with add-on relaxing incisions and were included in the retrospective analysis. The cohort included 58 women (69%) and 26 men (31%). The mean age was 62 years, with a range from 33 to 87 years. The average body mass index was 28 kg/m2, ranging from 19 to 41 kg/m2.
The underlying surgical indications were diverse and reflected the complexity of the cases. Thirty-two patients (38%) had symptomatic giant hiatal hernia, 25 (30%) had upside-down stomach, and 27 (32%) had recurrent hiatal hernia after previous repair. Three patients (3.6%) required emergency surgery.
Results
At a median follow-up of 24 months, outcomes were generally favorable. Among 77 evaluated patients, 59 (76.6%) reported no symptoms and 16 (20.8%) reported only mild symptoms. When assessed using the Visick score, a commonly used postoperative measure of symptom burden after antireflux surgery, the overall symptom profile suggested good functional results in most patients.
Heartburn improved markedly. Complete resolution of heartburn was reported in 84% of the cohort, corresponding to 65 patients. This is clinically important because heartburn is one of the most common and bothersome symptoms associated with reflux disease and recurrent hiatal failure.
A Visick score of 1, which reflects excellent symptom control, was reported in 26% of the redo group and in 50.6% of the upside-down stomach or paraesophageal hernia group. These findings suggest that even in complex cases, the combined approach can achieve meaningful symptom relief.
Only two patients reported symptoms consistent with a Visick score of 3, indicating more significant ongoing problems. One of these patients had undergone a third redo operation and most likely had symptoms related to vagal nerve injury rather than simple recurrence. Four patients were lost to follow-up, and three died from causes unrelated to surgery.
Interpretation
The main message of this analysis is that lateral relaxing incisions may help surgeons perform difficult hiatal repairs under less tension. This is important because tension is a major mechanical driver of recurrence. If the crura can be closed more naturally, the repair may be more durable.
The technique may be particularly useful in patients with recurrent hernias, large paraesophageal hernias, or distorted anatomy from previous operations. These patients often have poor tissue quality, scar formation, and a shortened esophagus or altered diaphragmatic geometry, all of which increase the risk that a standard repair will be under excessive strain.
The study also suggests that the procedure can be integrated into routine laparoscopic surgery without major technical barriers, at least in experienced hands. The avoidance of pleural injury is an important refinement, because it may reduce postoperative respiratory complications and intraoperative difficulties.
Clinical Significance
From a practical standpoint, this work adds to the ongoing effort to improve durability in hiatal hernia surgery. Recurrence remains one of the most frustrating problems in this field, especially after redo operations. Patients often undergo surgery because they want lasting symptom relief, yet recurrence can lead to renewed reflux, dysphagia, chest discomfort, or a return of herniation symptoms.
This study supports the idea that a tailored, anatomy-preserving tension-reduction strategy may be more helpful than relying on mesh alone. While mesh may still have a role in selected cases, the findings reinforce that better mechanics at the time of repair are crucial.
The patient-reported outcomes are also reassuring. Symptom improvement in 84.4% of the cohort indicates that most patients benefited clinically, not just anatomically. For patients, this matters more than any technical detail: they want to eat comfortably, avoid persistent heartburn, and reduce or discontinue medication when possible.
Limitations
As with many surgical series, this study has limitations. It was retrospective, meaning the analysis was based on previously collected data rather than a randomized comparison. There was no control group of similar patients who underwent hiatal repair without relaxing incisions, so it is not possible to prove that the new technique alone caused the favorable outcomes.
The sample size was modest, and the cohort was heterogeneous, including redo cases, giant hernias, and upside-down stomach. These groups differ in anatomy, surgical difficulty, and risk of recurrence. Follow-up was helpful but still limited for a condition where recurrence may appear years later.
In addition, the study relied partly on symptom-based outcomes. Although symptoms are highly relevant, they do not always perfectly match the presence or absence of anatomical recurrence. Long-term imaging or endoscopic follow-up will be needed to better define durability.
Conclusion
Redo hiatal hernia repair and surgery for giant paraesophageal hernia remain technically demanding procedures with a meaningful risk of failure. Lateral relaxing diaphragmatic incisions may offer a useful add-on technique by lowering tension at the hiatus and enabling a more secure, tension-free closure.
In this cohort, the approach was feasible and associated with good symptom outcomes, including substantial relief of heartburn and improvement in overall postoperative comfort. While these findings are encouraging, they do not yet establish the technique as a universal standard. Larger studies with longer follow-up and objective imaging are needed to determine whether this strategy truly reduces long-term recurrence.
For now, the study suggests that carefully selected relaxing incisions may be a valuable tool in the surgeon’s armamentarium for the most challenging hiatal hernia repairs.
