Proposed section structure
This topic is best organized around the clinical problem of failed or high-tension hiatal closure, followed by study design, technical details of the modified operation, patient-reported outcomes, interpretation in the context of existing evidence, and the remaining evidence gaps regarding anatomic recurrence.
Accordingly, the article is structured as follows: Highlights; Clinical background and unmet need; Study design and operative approach; Key findings; Clinical interpretation; Limitations and research priorities; Funding and trial registration; References.
Highlights
In a retrospective analysis of 84 patients undergoing complex hiatal hernia surgery, add-on lateral diaphragmatic relaxing incisions were technically feasible in giant, upside-down stomach, and redo hernia cases.
At a median follow-up of 24 months, 76.6% of evaluated patients reported no symptoms and another 20.8% reported only mild symptoms, based on patient-reported outcomes correlated with the Visick score.
Heartburn resolved completely in 84% of the cohort, suggesting good short- to mid-term symptomatic control after a tension-reducing hiatal repair strategy.
The central unanswered question is durability: the study provides symptom data but not long-term objective morphologic recurrence rates, which are essential in judging whether relaxing incisions outperform standard repair or mesh reinforcement.
Clinical background and unmet need
Laparoscopic antireflux surgery remains an established treatment for gastroesophageal reflux disease and paraesophageal hernia when symptoms, anatomy, or complications justify operative intervention. Although standard approaches are effective in many patients, the subgroup with giant paraesophageal hernias, upside-down stomach, or recurrent hiatal hernia after prior surgery remains particularly challenging. In these cases, the surgeon often confronts attenuated crura, distorted tissue planes, mediastinal scarring, shortened esophagus, obesity, or hostile revisional anatomy. All of these factors may increase tension at the crural closure and raise the risk of recurrent herniation.
This tension problem is clinically important because failure of the hiatal repair is one of the most frequent mechanisms of recurrence after antireflux and paraesophageal hernia surgery. The authors note recurrence rates in their earlier experience of 12% in redo cases and 18% in upside-down stomach cases. These figures are consistent with the broader literature, where reported radiographic recurrence rates after large hiatal hernia repair vary substantially depending on follow-up intensity, definition of recurrence, and operative technique.
Use of prosthetic or biologic mesh at the hiatus has long been proposed as a way to reinforce closure, especially when the crura are weak or under tension. However, the long-term benefit of mesh remains unsettled. Randomized and observational studies have shown mixed effects on recurrence, while concerns persist regarding dysphagia, erosion, fibrosis, and difficult reoperation. As a result, surgeons continue to seek alternatives that lower closure tension without introducing permanent foreign material directly at the hiatus.
Relaxing diaphragmatic incisions represent one such strategy. By making controlled incisions in the diaphragm lateral to the hiatus, the surgeon may reduce the force required to approximate the crura. The concept is analogous to tension-reduction techniques in other fields of reconstructive surgery: a repair under less stress may be less likely to pull apart. The present study evaluates a modified version of this technique in a European upper gastrointestinal practice, specifically designed to avoid pleural violation and capnothorax.
Study design and operative approach
Design and population
This was a retrospective analysis of prospectively collected data from a laparoscopic antireflux surgery database. The investigators included all patients operated on between September 2019 and October 2022 who underwent complex hiatal repair with add-on relaxing incisions. Median follow-up was 24 months.
The cohort comprised 84 patients, 69% women and 31% men, with a mean age of 62 years and a mean body mass index of 28 kg/m2. The case mix reflected difficult anatomy rather than a routine antireflux population: 32 patients had symptomatic giant hernia, 25 had upside-down stomach, and 27 underwent recurrent hiatal hernia repair. Three procedures were performed emergently.
Intervention
Patients underwent standard 5-port laparoscopic surgery with the addition of diaphragmatic relaxing incisions to reduce tension at the hiatal closure. Most received bilateral lateral relaxing incisions before crural approximation. Importantly, the authors modified the technique to avoid bisection of the pleura, with the goal of reducing capnothorax. This is a practical technical nuance, because pleural entry during hiatal dissection or diaphragmatic incision can compromise exposure and cardiopulmonary stability, especially in prolonged complex cases.
The abstract does not provide a comparator arm, and therefore this is best understood as a feasibility and outcomes series rather than a comparative effectiveness study. It also does not state whether defects created by the relaxing incisions were reinforced with mesh or how fundoplication type was selected. Those details matter when interpreting both symptom outcomes and recurrence risk.
Endpoints
The principal outcomes reported were patient-related and symptom-based: dysphagia, heartburn, proton pump inhibitor use, and global postoperative status correlated with the Visick score. The study did not report systematic radiographic or endoscopic recurrence as a primary endpoint, which limits conclusions about anatomic durability.
Key findings
Feasibility and short- to mid-term symptom outcomes
The main practical message is that the modified relaxing incision technique was applicable across a heterogeneous set of difficult cases. In experienced hands, the approach appeared technically feasible in redo surgery, giant paraesophageal hernia, and upside-down stomach.
Of the 77 patients available for evaluation, 59 patients, or 76.6%, reported no symptoms, while 16 patients, or 20.8%, reported only mild symptoms. Taken together, 84.4% experienced either complete or near-complete symptom control. This is a favorable patient-reported result in a population at intrinsically higher risk for persistent or recurrent symptoms.
Heartburn resolved completely in 84% of the cohort, corresponding to 65 patients. This is clinically relevant because reflux symptom control remains one of the most visible markers of success after hiatal reconstruction and antireflux surgery, even though it does not directly measure anatomic recurrence.
Visick outcomes by subgroup
A Visick score of 1, indicating no symptoms, was reported in 26% of the redo group and 50.6% of the upside-down stomach/paraesophageal hernia groups. This subgroup difference is not surprising. Revisional foregut surgery typically carries worse baseline tissue quality, altered anatomy, and higher rates of esophageal dysmotility or vagal injury, all of which may blunt postoperative symptom normalization even when the repair is technically sound.
Only two patients had symptoms corresponding to a Visick score of 3. One had undergone a third redo procedure and was thought to have symptoms likely related to vagal nerve injury. This detail underscores an important principle in foregut surgery: not all postoperative symptoms reflect recurrent hiatal failure. Functional syndromes, impaired gastric emptying, and denervation-related complaints may be major contributors, especially after repeated revisional operations.
Follow-up and missing data
Four patients were lost to follow-up, and three died of causes unrelated to surgery. The overall follow-up completeness appears reasonable for a retrospective surgical series, but attrition still matters in a relatively small cohort. In studies of recurrence-prone operations, missing outcome data can bias interpretation, particularly if symptomatic patients are more likely to seek care elsewhere or asymptomatic patients are less likely to return.
Clinical interpretation
Why the concept is attractive
The biological rationale for relaxing incisions is strong. Excessive tension at the hiatus may promote suture pull-through, dehiscence, and early recurrent migration of the stomach or wrap into the chest. In redo and giant hernia cases, surgeons may otherwise face a difficult trade-off: force a tight posterior closure, accept a compromised approximation, or place mesh at the hiatus. A relaxing incision potentially shifts that balance by permitting a more physiologic, less stressed closure with native tissue.
The modification described here is also practically important. Avoidance of pleural violation may reduce capnothorax and streamline intraoperative management. If that technical refinement is reproducible, it could increase acceptance of the method among surgeons who are otherwise reluctant to add diaphragmatic incisions in already complex cases.
What the study does and does not prove
The study supports feasibility and suggests that patient-reported outcomes after this technique can be good in challenging cases. That is meaningful, because many surgeons judge success not only by imaging but by symptom burden, dietary function, need for acid suppression, and reintervention.
However, the study does not establish that relaxing incisions reduce recurrence compared with standard repair, nor does it show superiority to selective mesh reinforcement. There is no control group, no adjustment for confounding, and no routine objective assessment of recurrence with contrast study, computed tomography, or endoscopy. Therefore, the findings should be interpreted as encouraging but hypothesis-generating.
This distinction is especially important in hiatal hernia surgery because symptom improvement and anatomic durability are related but not interchangeable. Some patients with small radiographic recurrence remain asymptomatic, whereas others have symptoms without demonstrable recurrence. A technique intended primarily to reduce closure tension should ideally be judged by both symptom outcomes and long-term morphologic endpoints.
Relationship to current evidence
Available literature shows persistent debate over optimal crural management in large and recurrent hiatal hernia. Early randomized data suggested that biologic reinforcement might reduce short-term recurrence, but long-term follow-up has generally not confirmed a durable advantage. Permanent synthetic mesh can reduce recurrence in some series, but concerns about erosion and stenosis have tempered enthusiasm. Current guideline discussions therefore emphasize individualized repair, careful mediastinal dissection, adequate esophageal length, selective use of Collis gastroplasty when needed, and prudent choices regarding reinforcement.
Against that background, relaxing incisions fit conceptually as a tissue-based tension-reduction maneuver rather than a prosthetic solution. They may be especially attractive in patients with broad hiatal defects, scarred or fibrotic crura, or recurrent hernias where posterior approximation is clearly under strain. Whether they should be paired routinely with patch reinforcement of the diaphragmatic release site or reserved for selected high-tension repairs remains an open question.
Limitations and research priorities
Several limitations constrain the conclusions. First, this was a retrospective single-center analysis without a comparator. Second, the cohort was heterogeneous, including giant hernias, upside-down stomach, and redo repairs, which may differ substantially in technical complexity and recurrence biology. Third, the main outcomes were subjective and patient-reported. Although highly relevant clinically, they cannot substitute for standardized objective recurrence assessment.
Further, the abstract provides limited procedural granularity. Important variables include hernia size definition, esophageal lengthening procedures, type of fundoplication, management of short esophagus, handling of the hernia sac, and whether the relaxing incision defects were covered or left untreated. Without these details, external reproducibility is reduced.
The next step should be prospective comparative study. An ideal design would compare high-tension standard cruroplasty versus cruroplasty plus relaxing incisions, with or without selective reinforcement, in redo and giant hernia subgroups. Core endpoints should include radiographic recurrence, symptomatic recurrence, quality of life, dysphagia, proton pump inhibitor use, reoperation, and procedure-specific complications. Follow-up beyond 3 to 5 years will be particularly important because hiatal recurrence often emerges over time.
It would also be useful to standardize how surgeons define a “high-tension” hiatus. Intraoperative tension scoring or video-based adjudication could make future studies more reproducible and help identify the subset most likely to benefit from this technique.
Bottom line for practice
For surgeons who manage complex paraesophageal and recurrent hiatal hernias, this study offers a practical message: lateral diaphragmatic relaxing incisions are a plausible adjunct when crural closure is difficult and tension appears excessive. The reported symptom outcomes are reassuring, particularly given the challenging case mix.
Still, the evidence is not yet strong enough to treat the technique as established standard of care. At present, it is best considered a selective expert maneuver for difficult repairs rather than a universally indicated modification. Decisions should continue to be individualized, integrating anatomy, prior operations, tissue quality, esophageal length, and the surgeon’s experience with revisional foregut reconstruction.
Funding and ClinicalTrials.gov
The abstract does not report a funding source. No ClinicalTrials.gov registration number is provided, which is consistent with the retrospective observational nature of the analysis.
References
1. 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. 2026-05-28:110242. PMID: 42209325.
2. Oelschlager BK, Pellegrini CA, Hunter J, Brunt M, Soper N, Sheppard B, Jobe B, Polissar N, Mitsumori L, Nelson J, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg. 2011;213(4):461-468.
3. Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD, Aly A, Jamieson GG. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial. Ann Surg. 2015;261(2):282-289.
4. Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z, Mittal SK, Richardson WS, Fanelli RD, SAGES Guidelines Committee. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409-4428.
5. Tam V, Winger DG, Nason KS. A systematic review and meta-analysis of mesh versus suture cruroplasty in laparoscopic large hiatal hernia repair. Am J Surg. 2016;211(1):226-238.
6. Andolfi C, Fisichella PM. Paraesophageal hernia repair: a curative approach to a disease with a high recurrence rate. J Laparoendosc Adv Surg Tech A. 2019;29(9):1137-1142.