Diaphragmatic relaxing incisions for complex hiatal reconstruction: longer-term follow-up confirms safety, efficacy and rare complications

Surg Endosc. 2023 Nov;37(11):8636-8643. doi: 10.1007/s00464-023-10293-6. Epub 2023 Jul 26.

Abstract

Background: Tension is an important factor in hernia repairs. Relaxing incisions to reduce tension are common with ventral hernia repairs, and techniques for relaxing incisions also exist for the hiatus. The aim of this study was to update our original experience with a diaphragm relaxing incision (DRI) in a larger group of patients with longer follow-up.

Methods: A retrospective chart review was performed to identify all patients who had a DRI between August 2016 and September 2021 during hiatal hernia repair. All DRI defects were repaired with permanent mesh remote from the esophagus. Objective follow-up was with chest x-ray, upper GI series (UGI) or both.

Results: Seventy-three patients had a total of 79 DRI (right in 63, left in 4, and bilateral in 6 patients), during a primary (n = 52) or redo (n = 21) hiatal hernia repair. Concomitant Collis gastroplasty was used in 38 patients (52%). A single intra-operative complication occurred where the right crus tore during a right DRI. At a median of 15 months, 78% of patients had objective follow-up. There was one hernia through a repaired right DRI (1.2%). No patient had evidence of diaphragm paralysis and there were no mesh infections. The 1-year hernia recurrence rate in these patients was 3.9%.

Conclusions: A DRI can be done safely with minimal risk of intra- or post-operative complications. There was a low rate of herniation through the defect when repaired with permanent mesh. No patient developed a mesh infection despite concomitant Collis gastroplasty in 52% of patients, and there was no evidence of diaphragm paralysis on imaging studies. Further, the low rate of hiatal hernia recurrence suggests efficacy of a DRI to reduce crural closure tension. These excellent outcomes should encourage use of a DRI in patients with a difficult hiatus during hernia repair.

Keywords: Collis gastroplasty; Diaphragm relaxing incision; Fundoplication; Hiatal hernia; Mesh; Paraesophageal hernia.

MeSH terms

  • Diaphragm / surgery
  • Follow-Up Studies
  • Fundoplication / methods
  • Hernia, Hiatal* / surgery
  • Herniorrhaphy / adverse effects
  • Herniorrhaphy / methods
  • Humans
  • Laparoscopy* / methods
  • Paralysis
  • Retrospective Studies
  • Surgical Mesh
  • Surgical Wound*
  • Treatment Outcome