Background
Laparoscopic antireflux surgery is a well-established treatment for gastroesophageal reflux disease (GERD), particularly in patients who do not respond adequately to medication or who prefer a durable surgical solution. In experienced hands, it can provide excellent symptom control and long-term quality-of-life improvement. However, one of the most challenging aspects of this surgery is the repair of the hiatal opening, or hiatus, where the esophagus passes through the diaphragm.
Hiatal repair failure is a recognized problem in two especially difficult situations: redo surgery for recurrent reflux or recurrent hiatal hernia, and primary repair of very large or giant hiatal hernias, including paraesophageal hernias and so-called upside-down stomach cases. These operations are technically demanding because scar tissue, altered anatomy, and chronic tissue stretching can create significant tension on the repair. High tension at the crura of the diaphragm is believed to increase the risk of recurrence.
Although mesh reinforcement at the hiatus has been widely used, long-term studies have not consistently shown that mesh prevents recurrence, and concerns remain about mesh-related complications. For this reason, surgeons continue to look for additional techniques that may reduce tension and improve the durability of the repair. One such concept is the use of diaphragmatic relaxing incisions made lateral to the hiatus, designed to release tension and allow the crura to come together more easily without excessive strain.
Objective
This study evaluated whether adding lateral relaxing incisions to difficult hiatal repairs was feasible and potentially helpful in patients undergoing redo surgery or repair of giant hiatal hernias. The authors were especially interested in whether this technique could reduce suture tension and support better patient-reported outcomes, such as improvement in heartburn and dysphagia, which may signal symptomatic recurrence if they persist or return.
Methods
The analysis included patients treated between September 2019 and October 2022 at a center with a prospective laparoscopic antireflux surgery database. All patients underwent standard laparoscopic surgery using a 5-port approach, with an added maneuver aimed at reducing tension during hiatal closure.
Most patients had bilateral relaxing incisions in the diaphragm made lateral to the hiatus before the crural repair was completed. The goal was to facilitate a tension-free approximation of the crura. The surgeons intentionally avoided opening the pleura to reduce the risk of capnothorax, a condition in which carbon dioxide enters the chest cavity during laparoscopy and may complicate the procedure.
The study population included patients with symptomatic recurrent hiatal hernia, giant hiatal hernia, upside-down stomach, and paraesophageal hernia. The authors assessed feasibility, short- to mid-term outcomes, and patient-reported symptoms after surgery. Outcomes of interest included dysphagia, heartburn, and ongoing proton pump inhibitor use. The results were correlated with the Visick score, a traditional measure of postoperative symptom control in antireflux surgery, where lower scores indicate better outcomes.
Results
A total of 84 patients were analyzed, with a median follow-up of 24 months. The cohort included 58 women and 26 men, with a mean age of 62 years and a mean body mass index of 28 kg/m2. Patients had several complex indications: 32 had symptomatic giant hernia, 25 had upside-down stomach, and 27 had recurrent hiatal hernia. Three patients underwent emergency surgery.
Overall, symptom outcomes were encouraging. Among 77 evaluated patients, 59 reported no symptoms and 16 reported only mild symptoms after surgery. Complete resolution of heartburn was documented in 84% of the cohort. When examined by subgroup, a Visick score of 1, reflecting excellent symptom control, was reported in 26% of redo cases and 50.6% of the upside-down stomach or paraesophageal hernia group.
Only two patients reported symptoms consistent with a Visick score of 3. One of these patients had undergone a third redo operation and likely had symptoms related to vagal nerve injury rather than simple hernia recurrence. Four patients were lost to follow-up, and three died from causes not related to the surgery.
From a practical standpoint, the technique appeared feasible in this complex surgical setting. The authors suggest that the relaxing incisions may have helped reduce tension on the hiatal closure, which is especially important in patients with scarred tissue, distorted anatomy, or significant hernia size.
Interpretation
The major challenge in recurrent or giant hiatal hernia repair is not simply closing the hiatus, but closing it without excessive tension. If the closure is too tight or under too much strain, the repair may fail over time. The rationale for diaphragmatic relaxing incisions is straightforward: by releasing surrounding tissue laterally, the surgeon may be able to bring the crura together more naturally and maintain a more stable repair.
This approach is appealing because it does not rely on permanent foreign material such as mesh. In addition, avoiding pleural entry may reduce the risk of thoracic complications. The technique may be particularly valuable in patients with large defects, previous operations, or poor tissue quality. It is also relevant in emergency settings, where anatomical distortion may be severe.
That said, this study mainly shows feasibility and favorable symptom outcomes rather than definitive proof that relaxing incisions reduce long-term recurrence. Patient-reported improvement is important, but it does not replace objective follow-up with imaging or endoscopy. A patient may feel well even if a small anatomical recurrence exists, and conversely, symptoms may recur for reasons unrelated to hernia repair failure.
Clinical Significance
This study adds to the ongoing search for better solutions in complex hiatal hernia surgery. For surgeons, it supports the idea that tension-reduction strategies deserve serious consideration, especially in redo operations and giant hernias where standard repair is likely to be difficult. For patients, it suggests that more durable symptom relief may be achievable when the repair is tailored to the anatomy and tension at the hiatus.
The results also highlight an important principle in upper gastrointestinal surgery: good outcomes often depend on adapting the technique to the individual patient rather than relying on a one-size-fits-all repair. In complex hiatal hernias, the balance between adequate closure and excessive tension is critical.
Limitations
As a retrospective analysis, this study has limitations. There was no randomized control group undergoing standard repair without relaxing incisions, so it is not possible to conclude definitively that the technique is superior. The sample size was modest, and the follow-up, while useful, was still not long enough to fully assess recurrence over many years. Also, symptom-based outcomes, although highly relevant to patients, do not always correlate perfectly with anatomical success.
Future studies should ideally include longer follow-up, objective radiologic or endoscopic assessment, and comparative evaluation against standard repair and mesh-based strategies. Such data would clarify whether relaxing incisions truly lower recurrence rates and improve durability in the long term.
Conclusion
Repair of recurrent hiatal hernia and giant paraesophageal hernia remains a difficult area of surgery. In this study, lateral diaphragmatic relaxing incisions appeared to be a feasible adjunct to hiatal repair and were associated with good symptom relief in most patients. About 84.4% of patients reported improvement in reflux symptoms or heartburn.
While these findings are promising, long-term objective follow-up is still needed to determine whether this technique can reliably reduce hernia recurrence and become a standard tool in challenging hiatal hernia repair.
Reference
Karunaratne R, Bergmann C, Widmann K, Convalexius C, Sebesta CG, Kisser M, Sebesta C, Prager MRE. Role of relaxing lateral incisions as an add-on to the difficult hiatal repair in redo and giant hernia cases. Surgery. 2026-05-29;195:110242. PMID: 42209325.
