title: Assessment and reduction of diaphragmatic tension during hiatal hernia repair.
abstract: BACKGROUND
  During hiatal hernia repair there are two vectors of tension: axial and radial. An optimal repair minimizes the tension along these vectors. Radial tension is not easily recognized. There are no simple maneuvers like measuring length that facilitate assessment of radial tension. The aims of this project were to: (1) establish a simple intraoperative method to evaluate baseline tension of the diaphragmatic hiatal muscle closure; and, (2) assess if tension is reduced by relaxing maneuvers and if so, to what degree.
  
  
  METHODS
  Diaphragmatic characteristics and tension were assessed during hiatal hernia repair with a tension gage. We compared tension measured after hiatal dissection and after relaxing maneuvers were performed.
  
  
  RESULTS
  Sixty-four patients (29 M:35F) underwent laparoscopic hiatal hernia repair. Baseline hiatal width was 2.84 cm and tension 13.6 dag. There was a positive correlation between hiatal width and tension (r = 0.55) but the strength of association was low (r (2) = 0.31). Four different hiatal shapes (slit, teardrop, "D", and oval) were identified and appear to influence tension and the need for relaxing incision. Tension was reduced by 35.8 % after a left pleurotomy (12 patients); by 46.2 % after a right crural relaxing incision (15 patients); and by 56.1 % if both maneuvers were performed (6 patients).
  
  
  CONCLUSIONS
  Tension on the diaphragmatic hiatus can be measured with a novel device. There was a limited correlation with width of the hiatal opening. Relaxing maneuvers such as a left pleurotomy or a right crural relaxing incision reduced tension. Longer term follow-up will determine whether outcomes are improved by quantifying and reducing radial tension.
authors: Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison St. Suite 900, Seattle, WA, 98104, USA.
authors: Daniel Davila
authors: DD
authors: Bradley
authors: Brian E
authors: BE
authors: Louie
authors: Alexander S
authors: AS
authors: Farivar
authors: Candice L
authors: CL
authors: Wilshire
authors: Peter U
authors: PU
authors: Baik
authors: Ralph W
authors: RW
authors: Aye
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003964:Diaphragm / Q000502:physiology*; D005260:Female; D005500:Follow-Up Studies; D006551:Hernia, Hiatal / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009129:Muscle Tonus; D012189:Retrospective Studies; D013526:Surgical Mesh; D016896:Treatment Outcome