Difficult Diaphragmatic Closure

  • Robert B. Yates
  • Brant Oelschlager
  • Andrew WrightEmail author


Tension-free closure of the esophageal hiatus is a key step to laparoscopic hiatal hernia repair. In the majority of patients, tension-free closure of the hiatus is achieved with the placement of simple interrupted sutures (i.e., posterior hiatoplasty). However, when the diaphragmatic crura are non-compliant and radial tension at the hiatus is elevated, primary closure of the hiatus may be impossible or only achievable under significant tension. Closure of the hiatus under tension is thought to be a contributing factor to the development of recurrent hiatal hernia, which is seen in >50 % of patients who undergo laparoscopic paraesophageal hernia repair. When faced with a challenging diaphragmatic closure, surgeons have several options: (1) Use mesh or an autologous tissue flap (e.g., falciform ligament or left triangular ligament) to reinforce the hiatal closure under tension or bridge the hiatus if it cannot be closed; (2) Create intentional pneumothorax or diaphragmatic (crural) relaxing incisions to reduce hiatal tension and allow primary closure of the hiatus; and (3) Perform a gastropexy without closure of the hiatus. When performed by experienced laparoscopic gastroesophageal surgeons, these techniques appear to be safe. However, systematic long-term clinical and radiographic follow-up are needed to assess their long-term ability to prevent recurrent hiatal hernia.


Hiatal hernia Paraesophageal hernia Diaphragm Diaphragmatic crus Relaxing incisions Recurrent hiatal hernia Esophageal hiatus Autologous tissue reinforcement 


  1. 1.
    Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, 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):461–8.CrossRefPubMedGoogle Scholar
  2. 2.
    DeMeester SR. Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence. Surg Laparosc Endosc Percutan Tech. 2013;23(5):429–35.CrossRefPubMedGoogle Scholar
  3. 3.
    Alicuben ET, Worrell SG, DeMeester SR. Resorbable biosynthetic mesh for crural reinforcement during hiatal hernia repair. Am Surg. 2014;80(10):1030–3.PubMedGoogle Scholar
  4. 4.
    Fortelny RH, Petter-Puchner AH, Glaser KS. Fibrin sealant (Tissucol) for the fixation of hiatal mesh in the repair of giant paraesophageal hernia: a case report. Surg Laparosc Endosc Percutan Tech. 2009;19(3):e91–4.CrossRefPubMedGoogle Scholar
  5. 5.
    Watson DI, Thompson SK, Devitt PG, Smith L, Woods SD, Aly A, et al. Laparoscopic repair of very large hiatus hernia with sutures versus absorbable mesh versus nonabsorbable mesh: a randomized controlled trial. Ann Surg. 2015;261(2):282–9.CrossRefPubMedGoogle Scholar
  6. 6.
    De Moor V, Zalcman M, Delhaye M, El Nakadi I. Complications of mesh repair in hiatal surgery: about 3 cases and review of the literature. Surg Laparosc Endosc Percutan Tech. 2012;22(4):e222–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Pérez Lara FJ, Fernández JD, Quecedo TG, Lafuente FC, Muñoz HO. Mesh extrusion into the esophageal lumen after surgery for a giant hiatal hernia. Am Surg. 2014;80(12):E364–6.PubMedGoogle Scholar
  8. 8.
    Tatum RP, Shalhub S, Oelschlager BK, Pellegrini CA. Complications of PTFE mesh at the diaphragmatic hiatus. J Gastrointest Surg. 2008;12(5):953–7.CrossRefPubMedGoogle Scholar
  9. 9.
    Wassenaar EB, Mier F, Sinan H, Petersen RP, Martin AV, Pellegrini CA, et al. The safety of biologic mesh for laparoscopic repair of large, complicated hiatal hernia. Surg Endosc. 2012;26(5):1390–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Stadlhuber RJ, Sherif AE, Mittal SK, Fitzgibbons RJ, Michael Brunt L, Hunter JG, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc. 2009;23(6):1219–26.CrossRefPubMedGoogle Scholar
  11. 11.
    Ward KC, Costello KP, Baalman S, Pierce RA, Deeken CR, Frisella MM, et al. Effect of acellular human dermis buttress on laparoscopic hiatal hernia repair. Surg Endosc. 2015;29(8):2291–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Oelschlager BK, Pellegrini CA, Hunter J, Soper N, Brunt M, Sheppard B, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006;244(4):481–90.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Van Helsdingen CF. Hiatal herniorrhaphy with posterior gastropexy utilizing the ligamentum teres hepatis. Int Surg. 1968;50(2):128–32.PubMedGoogle Scholar
  14. 14.
    Bradley DD, Louie BE, Farivar AS, Wilshire CL, Baik PU, Aye RW. Assessment and reduction of diaphragmatic tension during hiatal hernia repair. Surg Endosc. 2014;24:1–9.Google Scholar
  15. 15.
    Ponka JL. The relaxing incision in hernia repair. Am J Surg. 1968;115(4):552–7.CrossRefPubMedGoogle Scholar
  16. 16.
    Petro CC, Como JJ, Yee S, Prabhu AS, Novitsky YW, Rosen MJ. Posterior component separation and transversus abdominis muscle release for complex incisional hernia repair in patients with a history of an open abdomen. J Trauma Acute Care Surg. 2015;78(2):422–9.CrossRefPubMedGoogle Scholar
  17. 17.
    Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630–40.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Luketich JD, Grondin SC, Pearson FG. Minimally invasive approaches to acquired shortening of the esophagus: laparoscopic Collis-Nissen gastroplasty. Semin Thorac Cardiovasc Surg. 2000;12(3):173–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Oelschlager BK, Yamamoto K, Woltman T, Pellegrini C. Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure. J Gastrointest Surg. 2008;12(7):1155–62.CrossRefPubMedGoogle Scholar
  20. 20.
    Urbach DR, Khajanchee YS, Glasgow RE, Hansen PD, Swanstrom LL. Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery. Surg Endosc. 2001;15(12):1408–12.CrossRefPubMedGoogle Scholar
  21. 21.
    Lamb PJ, Myers JC, Jamieson GG, Thompson SK, Devitt PG, Watson DI. Long-term outcomes of revisional surgery following laparoscopic fundoplication. Br J Surg. 2009;96(4):391–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Ringley CD, Bochkarev V, Ahmed SI, Vitamvas ML, Oleynikov D. Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience. Am J Surg. 2006;192(6):767–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Varga G, Cseke L, Kalmár K, Horváth OP. Prevention of recurrence by reinforcement of hiatal closure using ligamentum teres in laparoscopic repair of large hiatal hernias. Surg Endosc. 2004;18(7):1051–3.CrossRefPubMedGoogle Scholar
  24. 24.
    Varga G, Cseke L, Kalmar K, Horvath OP. Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up: a new surgical procedure. Surg Endosc. 2008;22(4):881–4.CrossRefPubMedGoogle Scholar
  25. 25.
    Laird R, Brody F, Harr JN, Richards NG, Zeddun S. Laparoscopic repair of paraesophageal hernias with a falciform ligament buttress. J Gastrointest Surg. 2015;19(7):1223–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Park AE, Hoogerboord CM, Sutton E. Use of the falciform ligament flap for closure of the esophageal hiatus in giant paraesophageal hernia. J Gastrointest Surg. 2012;16(7):1417–21.CrossRefPubMedGoogle Scholar
  27. 27.
    Ghanem O, Doyle C, Sebastian R, Park A. New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament. Dig Surg. 2015;32(2):124–8.CrossRefPubMedGoogle Scholar
  28. 28.
    Monasch S. The relaxing incision in the anterior rectus sheath in the operative treatment of inguinal hernia. Arch Chir Neerl. 1965;17(1):13–21.PubMedGoogle Scholar
  29. 29.
    Pauli EM, Rosen MJ. Open ventral hernia repair with component separation. Surg Clin North Am. 2013;93(5):1111–33.CrossRefPubMedGoogle Scholar
  30. 30.
    Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ. Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia. 2014;19(2):285–91.CrossRefPubMedGoogle Scholar
  31. 31.
    Huntington T. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg. 1997;184(4):399–400.PubMedGoogle Scholar
  32. 32.
    Greene CL, DeMeester SR, Zehetner J, Worrell SG, Oh DS, Hagen JA. Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair. Surg Endosc. 2013;27(12):4532–8.CrossRefPubMedGoogle Scholar
  33. 33.
    Alicuben ET, Worrell SG, DeMeester SR. Impact of crural relaxing incisions, Collis gastroplasty, and non–cross-linked human dermal mesh crural reinforcement on early hiatal hernia recurrence rates. J Am Coll Surg. 2014;219(5):988–92.CrossRefPubMedGoogle Scholar
  34. 34.
    Yates RB, Hinojosa MW, Wright AS, Pellegrini CA, Oelschlager BK. Laparoscopic gastropexy relieves symptoms of obstructed gastric volvulus in highoperative risk patients. Am J Surg. 2015;209(5):875–80.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Robert B. Yates
    • 1
  • Brant Oelschlager
    • 1
  • Andrew Wright
    • 1
    Email author
  1. 1.Department of SurgeryUniversity of WashingtonSeattleUSA

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