Diaphragmatic Relaxing Incision in the Repair of Post-Esophagectomy Hiatal Hernia

OBJECTIVE: Hiatal hernia is a recognized long-term complication following esophagectomy. Approximating the crura around the tubular stomach is often challenging, especially in cases with a wide hiatus, resulting in high tension on the crura. This study evaluates the feasibility and outcomes of incorporating a diaphragmatic relaxing incision during post-esophagectomy hiatal hernia repair. METHODS: This retrospective single-center study included all post-esophagectomy patients who underwent repair for a hiatal hernia using a diaphragmatic relaxing incision from 2016 to 2024. Primary outcome measures included postoperative complications and hernia recurrence. RESULTS: Fifteen patients underwent hiatal hernia repair incorporating a diaphragmatic relaxing incision. The median interval between esophagectomy and diagnosis of hiatal hernia was 24 months (range, 2 to 99 months). The relaxing incision was performed on the left hemidiaphragm in 14 patients (93.3%) and on the right in 1 patient (6.7%). The median diameter of the hernia was 70 mm (range, 65 to 100 mm). Both the relaxing incision and the cruroplasty were reinforced with mesh. Postoperative complications occurred in 2 patients (13.3%), both consisting of transient dysphagia. During a median follow-up of 57 months (range, 14 to 105 months), 1 recurrence (6.7%) was identified 13 months postoperatively, requiring reintervention. CONCLUSIONS: This series represents, to our knowledge, the largest published cohort of post-esophagectomy hiatal hernia repairs using a diaphragmatic relaxing incision. This technique appears to be feasible and safe, facilitating tension-free crural approximation in patients with large hiatal defects. These outcomes should encourage experienced laparoscopic surgeons to consider this technique in patients with a wide hiatus during post-esophagectomy hernia repair.