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Page 4 of 7 Aiolfi et al. Mini-invasive Surg 2022;6:39 https://dx.doi.org/10.20517/2574-1225.2022.29

by Mor et al. compared the acid clearance time between Nissen fundoplication and Nissen-Collis
[33]
gastroplasty . They found a higher esophageal acid clearance time and pathologic esophageal acid
exposure in the Nissen-Collis group compared to the Nissen fundoplication one. This means that patients
may require chronic full dose long-term acid suppression medications.

Radial tension-definition and diagnosis
Relaxing incisions are commonly used as component separation maneuvers during large and complex
ventral hernia repair. The concept is that making a defect in an adjacent less critical area of muscle or fascia
allows the tissues to come together in the area of interest. In the setting of PEH repair, relaxing incisions
seem ideal because the diaphragm is theoretically available on each side, while repair of these new defects
[5]
with mesh has almost limited downside, thus allowing easier crura approximation with reduced tension .
Posterior cruroplasty is the main step of laparoscopic PEH repair, while tension-free crural closure has
always been indicated as crucial to achieving symptoms control and possibly reducing recurrence rate [3-5,34] .
Reconstruction of the diaphragmatic crura cannot be exempt from a careful evaluation of the complex
anatomical conformation and the forces that occur at the hiatus during everyday activities. In particular, the
diaphragm moves 15,000-20,000 times a day with respiration and contracts vigorously with coughing,
sneezing, or vomiting.

Radial tension is related to the splayed pillars that, in the case of large hernia, come together with substantial
tension. This is not as easily recognized, and there are no universally accepted maneuvers that may simplify
its assessment. For most surgeons, crural tension is assessed by tactile and visual clues during laparoscopic
approximation . However, these are prone to variability and have partial reproducibility . To overcome
[5,8]
[6]
these limitations and standardize the tension measurement at the hiatus, Bradley et al. first described a
laparoscopic calibrated tensiometer (Brief Pain Inventory Medical, Fife, WA®) . Specifically, the tension is
[4]
measured by placing the hooks at the hiatus during approximation, while multiple measurements are taken.
In the case that the tension is judged significant, relaxing incisions are considered.

Minimally invasive techniques and results
The use of relaxing maneuvers has an impact on the tension necessary to close the diaphragm and may
theoretically translate into a minor recurrence rate . Right- and left-sided relaxing incisions have been
[5]
[4,5]
described . The right-side incision is made by opening the right crus parallel to the inferior vena cava,
saving a 3 mm cuff of tissue along the cava to allow a patch to be sewn in place. This incision entails a full-
thickness section of the right crus into the right pleural space that should be opened before to exclude any
possible adhesion with the parenchyma. The incisions start in the midportion of the right crus and ends
below the anterior crural vein. The incision should not be extended inferiorly toward the aortic hiatus
because the posterior crura always easily come together. Furthermore, the thoracic duct would be at risk of
inadvertent injury. In contrast, the left-side incision starts to the left of the hiatus and follows the course of
the seventh rib laterally, saving a 1-2 cm cuff of diaphragm adjacent to the rib. To gain sufficient relaxation
of the left diaphragm, the incision may be extended lateral to the spleen. Attention should be paid to
avoiding damage to the phrenic nerve with paralysis of the left diaphragm. After incision, the diaphragmatic
defect is repaired with a polytetrafluoroethylene (PTFE) patch, while the crura is covered with an absorbable
mesh.

Few published studies reported data for diaphragmatic relaxing incision during laparoscopic HH repair.
Greene et al. in a 2013 retrospective study reported data on 15 patients who underwent paraesophageal
hernia repair and received relaxing incision to achieve crural closure . The relaxing incision was right-sided
[5]
in 13 patients, left-sided in 1 patient, and bilateral in 1 patient. All procedures were completed
laparoscopically and in all patients a fundoplication was fashioned [Nissen (n = 10) or Toupet (n = 5)]. The