Relaxing incision of the diaphragm for esophageal hiatal closure for giant paraesophageal hiatal hernia

Between December 1994 and December 2015, we performed 500 laparoscopic antireflux surgeries (LARS) in our clinic. Among them, we experienced 4 cases (0.8%) who had giant paraesophageal hiatal hernias (GPEH) with markedly enlarged esophageal hiatuses that made suturing of the right and left crus of the diaphragm difficult during crural repair. Therefore, we developed a procedure that allows crural repair without applying excessive tension after making a relaxing incision on the crus. This technique was applied in 5 cases in the current study. The mean surgical time and loss of bleeding volume were 280.2 +/- 45.7 (227-339) min and 46.0 +/- 87.1 (0-200) mL, respectively. No adverse events were observed during surgery, and no patients were converted to open surgery. No recurrent case has been observed after three sutures were added for fixation of the stomach and abdominal walls. This technique could be a safe and effective procedure for closure of the crural defect in GPEH.