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Background <p>Recurrence of hiatal hernia after paraesophageal hernia repair (PEHR) affects many patients, and axial tension is thought to be a major factor. A widely accepted guideline is that extensive esophageal mobilization to achieve at least 3&#xa0;cm of intra-abdominal esophageal length is important, and more length may further reduce recurrence, but there are minimal data to support this. We aimed to analyze the relationship between intra-abdominal esophageal length and recurrence in patients undergoing laparoscopic PEHR.</p> Methods <p>We conducted a retrospective study of adult patients undergoing laparoscopic paraesophageal hernia repair at a tertiary care institution from October 1, 2015, through January 31, 2024. Intra-abdominal esophageal length (EL) was measured prospectively by the operative surgeon after maximal esophageal mobilization. We investigated associations of intra-abdominal EL with radiographic recurrence at 6&#xa0;months, as well as with postoperative complications, using multivariable logistic regression adjusted for clinical and sociodemographic factors.</p> Results <p>183 patients were analyzed, with a median age of 68&#xa0;years and 76% were female. During PEHR, a fundoplication was performed in 99% of cases, mesh was used in 54%, and a relaxing incision was performed in 16%. The median intra-abdominal EL was 4.0&#xa0;cm (IQR 3.5–4.0&#xa0;cm). Recurrence occurred in 8.2% of patients. Overall, there was no statistically significant association between intra-abdominal EL and recurrence at 6&#xa0;months (adjusted Odds Ratio aOR 1.48, 95% CI 0.62–3.59, <i>p</i> = 0.38). This finding was robust to sensitivity analyses, including grouping intra-abdominal EL of &lt; = 3&#xa0;cm compared with &gt; 3&#xa0;cm and EL of &lt; = 4&#xa0;cm compared with &gt; 4&#xa0;cm.</p> Conclusions <p>The common practice to achieve as much intra-abdominal esophageal length as possible during PEHR may be questioned by these findings. Pending further studies, we propose that esophageal mobilization be viewed as more of a continuum than a target, recognizing that more may not be better.</p>

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“Is more better?”: association of intra-abdominal esophageal length in laparoscopic paraesophageal hernia repair with recurrent hiatal hernia

  • 期刊论文

  • 发表日期：

    2026年4月14日

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  • Irene Y. Zhang,
  • Laurel Tangalakis,
  • Vivian Hsiao,
  • Julia Persky,
  • Xiaoxiao Gao,
  • Andrew S. Wright,
  • Robert B. Yates,
  • Brant K. Oelschlager

摘要

Background

Recurrence of hiatal hernia after paraesophageal hernia repair (PEHR) affects many patients, and axial tension is thought to be a major factor. A widely accepted guideline is that extensive esophageal mobilization to achieve at least 3 cm of intra-abdominal esophageal length is important, and more length may further reduce recurrence, but there are minimal data to support this. We aimed to analyze the relationship between intra-abdominal esophageal length and recurrence in patients undergoing laparoscopic PEHR.

Methods

We conducted a retrospective study of adult patients undergoing laparoscopic paraesophageal hernia repair at a tertiary care institution from October 1, 2015, through January 31, 2024. Intra-abdominal esophageal length (EL) was measured prospectively by the operative surgeon after maximal esophageal mobilization. We investigated associations of intra-abdominal EL with radiographic recurrence at 6 months, as well as with postoperative complications, using multivariable logistic regression adjusted for clinical and sociodemographic factors.

Results

183 patients were analyzed, with a median age of 68 years and 76% were female. During PEHR, a fundoplication was performed in 99% of cases, mesh was used in 54%, and a relaxing incision was performed in 16%. The median intra-abdominal EL was 4.0 cm (IQR 3.5–4.0 cm). Recurrence occurred in 8.2% of patients. Overall, there was no statistically significant association between intra-abdominal EL and recurrence at 6 months (adjusted Odds Ratio aOR 1.48, 95% CI 0.62–3.59, p = 0.38). This finding was robust to sensitivity analyses, including grouping intra-abdominal EL of < = 3 cm compared with > 3 cm and EL of < = 4 cm compared with > 4 cm.

Conclusions

The common practice to achieve as much intra-abdominal esophageal length as possible during PEHR may be questioned by these findings. Pending further studies, we propose that esophageal mobilization be viewed as more of a continuum than a target, recognizing that more may not be better.