Background
Laparoscopic antireflux surgery is an established treatment for gastroesophageal reflux disease (GERD), especially when symptoms persist despite long-term medication or when patients prefer a durable surgical option. In addition to controlling reflux, surgery may also address hiatal hernias, which occur when part of the stomach moves upward through the diaphragm into the chest. Large and recurrent hiatal hernias are particularly challenging because the tissue at the hiatus often has to be repaired under significant tension.
In difficult redo operations, as well as in giant hiatal hernias and paraesophageal hernias, recurrence remains a major concern. Standard repair techniques sometimes fail because the crura of the diaphragm cannot be brought together without strain. Mesh reinforcement has been used widely, but long-term data have not consistently shown that it prevents recurrence. For this reason, surgeons continue to explore techniques that reduce tension on the repair itself.
One such approach is the use of lateral relaxing incisions in the diaphragm. These incisions are intended to release tension and allow the hiatal closure to be performed more safely and without excessive pulling on the sutures. The technique may be especially helpful in redo cases, where scar tissue and prior surgery increase the complexity of repair, and in giant hernias, where anatomy is markedly distorted.
Why relaxing incisions may help
The central idea behind relaxing incisions is straightforward: if the tissues around the hiatus are under too much tension, the repair is more likely to fail. By making small lateral cuts in the diaphragm, surgeons can reduce this tension and bring the crura together more naturally. In theory, this should improve the durability of the repair and reduce the chance of symptomatic recurrence.
In the present study, the surgical team used a slightly modified version of this technique. Most patients underwent bilateral relaxing incisions lateral to the hiatus before the hiatal closure was completed. The team intentionally avoided opening the pleura, the membrane surrounding the lungs, because that can lead to capnothorax, a condition in which carbon dioxide enters the chest cavity during laparoscopic surgery and may complicate the procedure.
Study objective
The purpose of this analysis was to assess the feasibility of this modified relaxing incision technique in a difficult patient population. The study focused on patients with either recurrent hiatal hernia after previous surgery or giant hiatal hernia, including cases of upside-down stomach and large paraesophageal hernias. The investigators also wanted to understand whether the technique was associated with favorable patient-reported outcomes, such as less heartburn, less dysphagia, and reduced need for proton pump inhibitor therapy.
Methods
This study reviewed patients from a prospectively maintained laparoscopic antireflux surgery database. All patients underwent standard five-port laparoscopic surgery with the addition of relaxing incisions to reduce tension at the repair site. The analysis covered operations performed between September 2019 and October 2022.
The included patients had one of the following conditions: symptomatic recurrent hiatal hernia, giant hiatal hernia, upside-down stomach, or paraesophageal hernia requiring complex repair. Patient outcomes were evaluated using postoperative symptom reports and correlation with the Visick score, a commonly used measure of gastrointestinal surgical outcomes in which lower scores indicate fewer symptoms and better function.
Researchers examined postoperative symptoms such as reflux, heartburn, and dysphagia, as well as ongoing proton pump inhibitor use. Follow-up was available for a median of 24 months, which provides useful medium-term information about symptom control after the operation.
Patient characteristics
A total of 84 patients were included in the study. The group consisted of 58 women and 26 men, with a mean age of 62 years. The mean body mass index was 28 kg/m2, indicating that many patients were in the overweight range, which can contribute to increased intra-abdominal pressure and hernia recurrence risk.
The surgical indications reflected the complexity of the cohort. Thirty-two patients had symptomatic giant hernias, 25 had upside-down stomach, and 27 had recurrent hiatal hernias. Three patients required emergency surgery. This mix of elective and urgent cases reflects the real-world challenge of managing advanced hiatal hernia disease.
Results
The findings suggest that the modified relaxing incision technique was feasible in this difficult surgical population. Among 77 patients with evaluable postoperative outcomes, 59 patients, or 76.6%, reported no symptoms, and 16 patients, or 20.8%, reported only mild symptoms. In practical terms, most patients had a good functional result after surgery.
Complete resolution of heartburn was recorded in 84% of the cohort, which is clinically important because reflux symptoms are one of the main reasons patients undergo hiatal hernia repair and antireflux surgery. Improvement in reflux symptoms was reported by 84.4% of patients overall.
When outcomes were assessed using the Visick score, 26% of patients in the redo surgery group achieved a score of 1 after surgery, while 50.6% of patients in the upside-down stomach or paraesophageal hernia group achieved this best-outcome category. Only two patients reported symptoms that corresponded to a Visick score of 3, indicating more significant ongoing symptoms. One of these patients had already undergone a third redo operation and likely had symptoms related to vagal nerve injury, which can occur in complex reoperative upper gastrointestinal surgery.
Four patients were lost to follow-up, and three died from causes unrelated to surgery. These losses should be kept in mind when interpreting the results, but they do not appear to undermine the overall favorable symptom profile reported in the majority of patients.
Clinical interpretation
These results support the concept that tension reduction is an important part of difficult hiatal hernia repair. The diaphragm is a dynamic muscular structure, and closures under high tension are at risk of pulling apart over time. By using relaxing incisions, surgeons may be able to improve the mechanical conditions at the hiatus, making the repair more durable.
The study does not prove that relaxing incisions eliminate recurrence, and it does not replace the need for long-term imaging or endoscopic follow-up. However, it does show that the technique can be used safely and may be associated with good symptom relief in a complex group of patients who have traditionally been difficult to treat.
It is also worth noting that symptom improvement does not always perfectly match anatomic success. Some patients may feel well even if a small recurrence develops, while others may have symptoms despite a technically adequate repair. For that reason, objective follow-up with imaging, endoscopy, or functional testing remains essential.
Advantages and limitations
A major advantage of the technique is that it offers a simple, anatomy-based way to reduce tension without relying entirely on mesh reinforcement. This is attractive because mesh at the hiatus has been associated with concerns about erosion, fibrosis, and uncertain long-term benefit. Relaxing incisions may therefore provide a useful adjunct in selected patients.
However, the study also has limitations. It was retrospective, involved a single experience, and lacked a randomized comparison group. The number of patients was relatively small, and the follow-up, while useful, was not long enough to determine true recurrence rates over many years. In addition, symptom reporting, although clinically meaningful, is not the same as objective confirmation of anatomical durability.
What this means for patients
For patients facing redo hiatal hernia surgery or repair of a giant paraesophageal hernia, this study is encouraging. It suggests that surgeons may be able to improve the quality of repair by using lateral relaxing incisions to decrease tension. Many patients in the study experienced relief from heartburn and had little or no postoperative symptoms.
Still, hiatal hernia surgery remains complex, and results depend on anatomy, prior operations, comorbidities, and surgical expertise. Patients should understand that the goal is not only to close the hiatus but to create a repair that can withstand long-term movement and pressure in the upper abdomen.
Conclusion
Recurrent hiatal hernia and giant paraesophageal hernia remain difficult surgical problems. In this study, a modified technique using lateral diaphragmatic relaxing incisions appeared feasible and was associated with substantial symptom improvement, including high rates of heartburn resolution. The approach may help surgeons achieve a more tension-free hiatal closure in challenging redo and giant hernia cases.
Long-term follow-up with objective anatomic data will be essential to determine whether this strategy truly lowers recurrence rates and should become a standard adjunct in complex hiatal hernia repair.