Quantifying tension in tension-free hiatal hernia repair: a new intra-operative technique



A similar technique to measure crural closure tension has not been described before and with this method there is now a possibility to optimise this operation with objective measures, a hundred years after it was first described. The aims of this study were to develop a reliable method for measuring the tension of crural closure during hiatal hernia repair and to describe the tension characteristics of crural closure.


50 patients underwent crural tension measurement. Hiatal surface area (HSA) was measured intraoperatively and a Sauter FH 50 Universal Digital Force Gauge was used to measure the tension of crural closure during cruroplasty. Outcome measures included the mean tension of the crural closure and the presence of any muscle splitting during the cruroplasty.


A combined total of 148 interrupted cruroplasty sutures were performed in all fifty patients. Each interrupted suture had three tension measurements recorded. The mean standard deviation amongst 148 sets of tension measurements was 0.27. Age, hiatal width and HSA were positively correlated with crural tension with r values of 0.44 (p = 0.0015), 0.81 (p < 0.0001) and 0.78 (p < 0.0001), respectively. Strength of association was low for age (r2 = 0.19) but moderate for hiatal width and HSA (r2 = 0.65 and 0.61, respectively). The presence of muscle splitting occurred at higher crural closure tension (5.3 N vs. 1.62 N, p < 0.0001). The lowest observed mean crural closure tension causing muscle splitting was 3.52 N (IQR 3.93–6.77 N).


We have developed a technique for measuring the tension of crural closure during laparoscopic repair of hiatal hernia which is reproducible, quick, of low cost and requires only minimal additional equipment. Initial findings suggest that crural closure tension up to ~ 4 N could be the permissible tension threshold for suture cruroplasty and higher tension often results in muscle splitting during cruroplasty.

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The authors thank Cally Kilduff for the illustrations.


Department of Upper GI Surgery, Northwick Park & St Mark’s Hospitals, Watford Road, Harrow, London, HA1 3UJ, United Kingdom. There were no other sources of funding from other organisations

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Correspondence to Lalin Navaratne.

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Lalin Navaratne, Hutan Ashrafian and Alberto Isla have no conflicts of interest or financial ties to disclose.

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Navaratne, L., Ashrafian, H. & Martínez-Isla, A. Quantifying tension in tension-free hiatal hernia repair: a new intra-operative technique. Surg Endosc 33, 3040–3049 (2019) doi:10.1007/s00464-019-06843-6

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  • Suture cruroplasty
  • Mesh cruroplasty
  • Crural tension measurement
  • Hiatal hernia
  • Hiatal surface area