Difficult Diaphragmatic Closure

Abstract

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.