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Aiolfi et al. Mini-invasive Surg 2022;6:39 https://dx.doi.org/10.20517/2574-1225.2022.29 Page 5 of 7

diaphragmatic defect created by either relaxing incision was repaired with a PTFE patch, while crural
closure was buttressed with absorbable mesh. The authors reported encouraging results in term of
postoperative recurrence rate (10%) in a short-term follow-up (median 15 months) with 27% complication
rate [pleural effusion (n = 3) and pulmonary embolism (n = 1)]. Similarly, Bradley et al. in 2014 reported
outcomes for 33 patients who underwent PEH repair with concomitant relaxing maneuver: iatrogenic left
[4]
pneumothorax without diaphragmatic incision (n = 12), right relaxing incision (n = 15), and both (n = 6) .
Left diaphragmatic incision was not performed. The authors described significantly reduced crural basal
tension after left pneumothorax, left pneumothorax plus right diaphragmatic incision, and right
diaphragmatic incision alone. They concluded that, when tension is deemed to be significant, creation of a
left pneumothorax and/or a right diaphragm relaxing incision will significantly reduce tension. Alicuben et
[9]
al., in a retrospective 2014 article, reported data for 82 patients treated for symptomatic PEH . Overall, 10
patients (12%) required crural relaxing incision to close the primary defect; specifically, the authors
performed eight right side incisions, one left side one, and in one case the incision was bilateral. The most
common postoperative complication was pleural effusion, managed successfully with percutaneous
drainage in most of the patients.

To further reduce tension at the hiatus, different buttressing techniques for crural reinforcement have been
described . Even though their use is controversial, different type of meshes with various shapes (i.e.,
[35]
keyhole, reverse C-shape, U-shape, etc.) have been reported to reinforce the hiatus and possibly release
[36]
crural tension . A permanent synthetic mesh has been reported to reduce the hernia recurrence rate, but at
the risk of infection, stricture, and esophageal-gastric erosion [37,38] . This seems related to the chronic
“sawing” motion of the esophagus over the mesh with each swallow. An alternative to non-resorbable mesh
is an absorbable or biologic mesh [39,40] . Absorbable meshes were introduced with the intent to decrease the
hernia recurrence rate without the related morbidity of non-absorbable meshes. These may be biologic or
synthetic. While their safety over non- absorbable meshes is often discussed, long-term efficacy and cost-
effectiveness remain controversial. Theoretically, the ideal mesh should assist in reinforcing crural repair
without undue tension, erosion, or dysphagia, combined with long-term durability. Unfortunately, the ideal
mesh material has yet to be realized, and, nowadays, the SAGES guidelines conclude there is insufficient
[41]
evidence for or against the use of mesh .

CONCLUSIONS
Axial and radial are two vectors of tension that should be considered when performing laparoscopic HH
repair. Axial tension is assessed intraoperatively by a short esophagus (< 2 cm), which has an estimated
incidence of up to 20%. Laparoscopic wedge fundectomy is the most commonly adopted minimally invasive
technique for esophageal lengthening (Collis gastroplasty). Results related to lengthening procedures are
heterogeneous with a not negligible risk of postoperative dysphagia and chronic GERD. Radial tension is
not easily recognized, while its objective assessment and measurement are challenging. Different techniques
for diaphragmatic relaxing incision have been described in an attempt to reduce radial tension; however,
evidence is weak and results heterogeneous. Therefore, there are insufficient data to recommend these
approaches.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Aiolfi A, Sozzi A, Bona D
Performed data acquisition, as well as provided administrative, technical, and material support: Aiolfi A,
Sozzi A, Bona D