There were no mesh-related learn more complications and no operative mortality. Objective follow-up was available in 69 patients at a median of 5 months

postoperatively, and in 15 patients at 1 or more years. The follow-up was by videoesophagram in 79%, upper endoscopy in 52%, and both in 48% of patients. Two patients underwent conversion from a Nissen to a Toupet for protracted dysphagia. A small recurrent hernia was found in 3 patients (4%) by upper endoscopy, but no patient has required reoperation. All recurrences developed after primary laparoscopic repair of a PEH (n = 2) or sliding hiatal hernia (n = 1). One recurrence was in a patient who had a Collis gastroplasty and a right relaxing incision; no adjunct procedures were performed in the other 2 patients. A recurrent hiatal hernia is the most common form of anatomic failure after laparoscopic hiatal hernia repair and fundoplication.1

Hernia recurrence is particularly common after laparoscopic PEH repair; the rate exceeds 50% at 5 years when objective studies such as barium swallow or upper endoscopy are done to evaluate the repair.1 and 2 These recurrence rates ATM/ATR phosphorylation are higher than those in historic reports with open repairs.1 and 8 The explanation for the higher recurrence rate with laparoscopic repair is unclear, but theories include the lack of deep bites during crural closure with the use of laparoscopic suturing devices and reduced adhesions associated with a laparoscopic compared with an open procedure. However, an alternative explanation is that during laparoscopic repairs there may be an underappreciation of tension on the repair. This tension can come from 2 directions: axial tension related to esophageal shortening and lateral tension related to widely splayed crura that must be reapproximated as part of the repair. The consequences of tension on hernia recurrence are well documented at other Dipeptidyl peptidase sites including inguinal and ventral hernias.9 In an effort to reduce tension and improve outcomes with laparoscopic hiatal hernia repair, we adopted adjunct techniques to reduce tension when encountered. These techniques included a diaphragm relaxing incision or a wedge-fundectomy Collis

gastroplasty. In this series, a crural relaxing incision was performed in 12% and a Collis gastroplasty in 28% of patients. These numbers increased to 21% and 45%, respectively, in those undergoing PEH repair. In part, these high numbers are related to the addition of patients undergoing reoperations when tension was likely a contributing factor to the initial failure, but also to the complexity of patients who are sent to a tertiary referral center. When a relaxing incision was deemed necessary, it was most commonly performed on the right side. This is the easiest of the diaphragmatic relaxing incisions. If the right side relaxing incision was inadequate, or if the right crus was too thin to allow a relaxing incision, then a left-sided diaphragmatic relaxing incision was used.