THE IMPACT OF RIGHT DIAPHRAGMATIC RELAXING INCISION ON OUTCOMES AND RECURRENT HIATAL HERNIAS IN PARAESOPHAGEAL HERNIA REPAIR
Lancy M. Tan*, Alexander S. Farivar, Ralph W. Aye, Adam J. Bograd, Brian E. Louie
Thoracic Surgery, Swedish Medical Center, Seattle, WA
Introduction:
During repair of a paraesophageal hernia, surgeons must assess and mitigate axial tension along the esophagus and radial tension at the crural closure. Failure to recognize and address these tension points has contributed to high recurrence rates in paraesophageal hernia repair. Radial tension along the crural sutures can be reduced by performing a relaxing incision in either the right or left diaphragm with the goals of hiatal closure and recurrence prevention. Despite this, there is limited data documenting the outcomes following this adjunctive maneuver. The aim of this study was to compare outcomes with and without right diaphragmatic relaxing incision during paraesophageal hernia repair.
Methods:
We performed a retrospective case-control study of patients with a type III paraesophageal hernia undergoing primary laparoscopic repair and Nissen fundoplication from May 1, 2013 to March 31, 2015. Patients were grouped based on the presence or absence of a relaxing incision. Patients were excluded if the repair was emergent/urgent or if Hill gastroplasty sutures were used. Data collected included demographics, preoperative workup, symptoms, complications, reoperation, and recurrence. Recurrence was identified on UGI or EGD and defined as any detectable stomach above the diaphragm.
Results:
There were 100 patients meeting criteria and undergoing repair: 44 patients underwent right diaphragmatic relaxing incision (RI) and 56 underwent repair without relaxing incision (NRI). The mean age of RI group was 68 years and NRI group was 62 (p=0.03). Average BMI of RI group was 28.0 and NRI group was 29.8 (p=0.07). Biosynthetic mesh was used in 40 (91%) to cover the diaphragmatic relaxing incision. The RI group had significantly larger hiatal hernia size (7.1 cm) than the NRI group (4.9 cm, p<0.01).
Objective evaluation (UGI or EGD) occurred in 28/44 (64%) of the RI group at a median of 6.9 months after surgery; compared to 39/56 (70%) of the NRI group of 10.6 months. Recurrence rates were lower in RI group (7/28, 25%) compared to NRI group (17/39, 44%) (p=0.12). Symptomatic recurrences occurred in 3 (7%) of RI group and 15 (14%) in NRI group (p=0.24). Re-operation rates were similar between the two groups (6.8% for RI, 5.4% for NRI, p=0.76). There was one herniation through a relaxing incision resulting in gastric perforation at 9 months after initial surgery that was repaired without complication. Mean GERD-HRQL score improved from 17.0 to 2.9 in the RI group; whereas, it improved from 21.1 to 7.8 in the NRI group.
Conclusion:
The use of a right diaphragmatic relaxing incision appears to reduce the rate of anatomic hernia recurrence for patients undergoing paraesophageal hernia repair. Consideration should be given to a relaxing incision when hiatal tension is encountered during hiatal hernia repair.
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