Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair.
BACKGROUND
Laparoscopic paraesophageal hernia (PEH) repair is associated with an objective recurrence rate exceeding 50% at 5 years. Minimizing tension is a critical factor in preventing hernia recurrence. This study aimed to evaluate the outcomes of crural relaxing incisions in patients undergoing PEH repair.


METHODS
Records were reviewed to identify patients who received a relaxing incision during laparoscopic PEH repair. The patients were followed by chest X-ray and videoesophagram at 3 months and then annually.


RESULTS
From November 2010 to March 2013, 58 patients underwent PEH repair, and 15 patients received a relaxing incision to accomplish crural closure. The median age of the patients was 72 years (range 58-84 years). The relaxing incision was right-sided in 13 patients, left-sided in one patient, and bilateral in one patient. All the procedures were completed laparoscopically and included a fundoplication. Collis gastroplasty for a short esophagus was performed for 40% of the patients. No major complications occurred. During a median follow-up period of 4 months, one patient had an asymptomatic mildly elevated left hemidiaphragm, and one patient had a trivial recurrent hernia, as shown on esophagogastroduodenoscopy (EGD).


CONCLUSIONS
Crural tension likely contributes to the high recurrence rate noted with laparoscopic PEH repair. Relaxing incisions are safe and allow crural approximation. Advanced laparoscopic surgeons should be aware of this option when faced with a large hiatus in a patient with PEH.
The Keck School of Medicine of the University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA, 90033, USA, christina.greene@med.usc.edu.
Christina L
CL
Greene
Steven R
SR
DeMeester
Joerg
J
Zehetner
Stephanie G
SG
Worrell
Daniel S
DS
Oh
Jeffrey A
JA
Hagen
D000368:Aged; D000369:Aged, 80 and over; D003964:Diaphragm / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication; D015391:Gastroplasty; D006551:Hernia, Hiatal / Q000175:diagnosis / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055502:Secondary Prevention; D016896:Treatment Outcome