Role of relaxing lateral incisions as an add-on to the difficult hiatal repair in redo and giant hernia cases.

Abstract

Laparoscopic antireflux surgery has proven to be a successful treatment alternative to lifelong medical treatment of gastroesophageal reflux disease. Several studies have shown that laparoscopic antireflux surgery is both safe and effective with excellent long-term functional outcomes. Failure of the hiatal repair is common to both redo reflux procedures and surgery for large or giant hiatal hernias. Looking at our own data collected between January 2016 and September 2019, we found recurrence rates as high as 12% in the redo and 18% in the upside-down stomach subgroups of complex hiatal hernia repair cases. While the use of mesh at the hiatus is still widespread, long-term results have not shown a benefit in preventing hernia recurrence. It has been postulated that tension reduction techniques in the form of lateral relaxing diaphragmatic incisions at the hiatus facilitate a tension-free repair and may prove to be beneficial in long-term hernia recurrence. We conducted this analysis of a subgroup of patients with giant hiatal hernia or redo hiatal hernia repair to determine the feasibility of a modified relaxing incision technique in reducing suture tension at the hiatus and to assess patient-related outcomes indicative of symptomatic recurrence. Patients with either symptomatic recurrent hiatal hernia or giant hernia received the standard 5-port surgical therapy with an add-on to reduce tension at the hernia repair sutures. Most patients received bilateral relaxing incisions of the diaphragm lateral to the hiatus prior to hiatal repair to facilitate tension-free crural approximation; we avoided bisection of the pleura to prevent the occurrence of capnothorax. This study looked at the feasibility and applicability of this slightly modified technique that has yet to gain widespread acceptance in the European upper gastrointestinal surgical community. We analyzed data taken from our prospectively established laparascopic antireflux surgery database regarding patient-related outcomes, such as dysphagia, heartburn, and current proton pump inhibitor use. We retrospectively analyzed the data of all patients we had operated on with add-on relaxing incisions in the period between September 2019 and October 2022 with a median follow-up of 24 months: 84 patients (female: n = 58, 69%; male: 26, 31%), with a mean age of 62 years (33-87, standard deviation 12) and a mean body mass index of 28 kg/m² (19-41 kg/m²). All patients with symptomatic giant hernia (n = 32, 38%), upside-down stomach (n = 25, 30%), and recurrent hiatal hernia (n = 27, 32%) were included; 3 of these (3.6%) received emergency procedures. Based on the patient-reported outcomes following surgery and correlation with the Visick score, an overall of 59 (76.6%) and 16 (20.8%) of 77 evaluated patients reported no and only mild symptoms, respectively. Complete resolution of heartburn was recorded in 84% (n = 65) of the cohort. A Visick score of 1 after surgery was reported in 26% of the redo and 50.6% of the upside-down stomach/paraesophageal hernia groups. Two patients complained of symptoms that correlated with a Visick score of 3; 1 of these patients had undergone their third redo procedure and presented with symptoms most likely attributable to vagal nerve injury. Four patients were lost to follow-up, whereas another 3 died of causes unrelated to the surgery. Surgical therapy of recurrent hiatal hernia and large paraesophageal hernia is challenging. Diaphragmatic relaxing incisions may allow for tension-free hiatal repair in a heterogenous patient cohort with comorbidities associated with the risk of high tension at the site of crural repair. Patients (84.4%) in our cohort reported improvement in reflux symptoms or heartburn. Long-term follow-up with objective morphologic data will determine the role of this technique in challenging hiatal hernia repair.