ArticleSurgical endoscopy2026
"Is more better?": association of intra-abdominal esophageal length in laparoscopic paraesophageal hernia repair with recurrent hiatal hernia.
Article in Surgical endoscopy, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundRecurrence 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.
methodsWe 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.
results183 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.
conclusionsThe 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.
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