{"paper_id":"00d9e138-2efa-4353-8259-3db3bcf8e1b1","body_text":"Innovative Laparoscopic 'Tunnel' Approach in Managing Hiatal Hernia with gastroesophageal reflux disease: A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Innovative Laparoscopic 'Tunnel' Approach in Managing Hiatal Hernia with gastroesophageal reflux disease: A Retrospective Study Zhewen Feng, Zhiping Zhang, Zhilong Yan, Feng Gao, Qingfeng Chen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6041499/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2025 Read the published version in BMC Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background Hiatal hernia (HH) is a major cause of gastroesophageal reflux disease (GERD), and laparoscopic repair combined with anti-reflux surgery is a common treatment. However, postoperative complications such as vagus nerve injury remain a concern. This study introduces a novel Laparoscopic \"Tunnel\" Approach aiming to minimize damage to the vagus nerve and preserve perigastric vessels. Methods A retrospective analysis was conducted on 106 patients who underwent the Laparoscopic \"Tunnel\" Approach for HH and GERD at the First Affiliated Hospital of Ningbo University from June 2023 to June 2024. Data collected included age, gender, BMI, DeMeester score, surgical time, and postoperative symptoms. Follow-ups were conducted at 1, 3, and 6 months postoperatively. Results The average age was 54 ± 9 years, BMI was 25.56 ± 4.32 kg/m², DeMeester score was 118.05 ± 17.71, and GERD-Q score was 13 ± 2. The average surgical time was 115 ± 15 minutes. Postoperatively, symptoms significantly improved, with an average GERD-Q score of 5 ± 1 at 6 months. At 1 month, dysphagia was observed in 14 patients, belching in 19, abdominal distension in 5, nausea in 16, and diarrhea in 8. By 6 months, only 2 patients exhibited belching, with no other symptoms persisting. No cases of vomiting or gallstones were reported. Conclusions The Laparoscopic \"Tunnel\" Approach effectively minimizes vagus nerve injury and preserves perigastric vessels, resulting in improved postoperative outcomes and quality of life. This method shows potential for wider application in treating HH and GERD. Hiatal Hernia gastroesophageal reflux disease Laparoscopic surgery Vagus nerve Figures Figure 1 Figure 2 Background Hiatal hernia (HH) refers to the condition where abdominal contents enter the thoracic cavity through the esophageal hiatus of the diaphragm and is considered a primary cause of gastroesophageal reflux disease (GERD)[ 1 ]. Laparoscopic repair of HH combined with anti-reflux surgery is suitable for patients with chronic symptoms of HH and GERD, those who are refractory to proton pump inhibitors (PPI), or those unwilling to take PPIs for life. The treatment goal for HH combined with GERD is to achieve optimal long-term control of reflux symptoms and signs with minimal or no side effects. Despite continuous improvements in surgical techniques[ 2 ], postoperative complications still occur[ 3 , 4 ]. Vagus nerve injury is a common complication of laparoscopic HH repair combined with fundoplication[ 5 ]. Studies have shown that approximately 10–20% of GERD patients experience vagus nerve injury after anti-reflux surgery[ 5 , 6 ]. Vagus nerve injury can lead to postoperative symptoms such as diarrhea, nausea, vomiting, gastric emptying disorders, belching, and abdominal bloating, and can also increase the incidence of gallstones[ 7 , 8 ]. In 20-year follow-up data, patients with vagus nerve injury had significantly worse outcomes in terms of gastroesophageal reflux symptoms, satisfaction rates, and reoperation rates[ 5 ]. The traditional bilateral surgical approach (TBSA) is the main surgical method for laparoscopic HH repair combined with fundoplication[ 9 ]. A disadvantage of TBSA is that although it can provide local protection of the vagus nerve during surgery, it cannot assess the integrity of the vagus nerve, potentially causing undetected nerve damage[ 10 ]. Other surgical approaches, such as the total left-sided approach (TLSA), can effectively avoid iatrogenic damage to the main trunk of the vagus nerve and its hepatic branches[ 11 ]. However, TLSA requires incision of the gastrocolic ligament, inevitably splitting some short gastric and gastroepiploic vessels, restricting the venous blood flow around the stomach, and increasing the risk of gastric emptying disorders. Moreover, the ligation of short gastric vessels poses a potential hazard for preserving the proximal stomach in subsequent gastric surgeries. Therefore, based on the existing surgical defects, our center innovatively proposes a new surgical approach—the Laparoscopic \"Tunnel\" Approach. The potential advantages of this method are that it not only minimizes damage to the main trunk of the vagus nerve and its hepatic branches but also preserves all perigastric vessels, such as the short gastric vessels. Methods A retrospective analysis was conducted on patients who underwent laparoscopic \"tunnel\" approach for the treatment of hiatal hernia combined with gastroesophageal reflux disease at the First Affiliated Hospital of Ningbo University from June 2023 to June 2024. Inclusion criteria: 1) Patients with a definitive diagnosis of gastroesophageal reflux disease; 2) Age 25–80 years; patients and their families have good compliance and can cooperate with the treatment; 3) No severe diseases of important organs such as heart, brain, and lungs; 4) No patients with severe anxiety or depression; 5) Meet the surgical indications. Exclusion criteria: 1) Change of surgical method due to special circumstances during surgery; 2) Loss to follow-up, accidental events, or severe somatic diseases. Surgical indications: 1) Major complications of hiatal hernia or gastroesophageal reflux disease, such as severe esophagitis, Barrett's esophagus, etc. 2) Patients who have undergone full and systematic drug therapy for more than half a year but still cannot alleviate and eliminate the complications of reflux disease. 3) Patients who have undergone Heller myotomy for esophageal motility disorders to prevent recurrence of gastroesophageal reflux. 4) Patients whose recurrent laryngeal and pulmonary diseases are determined to be caused by reflux disease, as well as those with asthma caused by reflux disease. 5) Patients who have relapsed after surgery and have severe reflux symptoms, or patients with paraesophageal hernia with reflux symptoms that are not successfully treated with drugs. 6) Patients with severe atypia or cancerous changes in pathological examination of cells. All patients signed an informed consent form before surgery. The collected clinical data included: age, gender, height, weight, BMI, DeMeester score, hiatal hernia classification, quality of life score (GERD-Q score), surgical time, blood loss, etc. The present study was approved by the Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 2025-024RS). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Laparoscopic \"Tunnel\" Surgical Approach Steps Expose the hepatogastric ligament at the lesser curvature of the stomach. Incise an area on the hepatogastric ligament that is free of blood vessels, nerves, and adipose tissue. Anatomically, this area is devoid of nerve passage (Fig. 1 a). Incise the peritoneum at the outer edge of the right crus of the diaphragm, and bluntly dissect the loose tissue at the lower end of the esophagus to expose the junction of the left and right crus of the diaphragm (Fig. 1 b). Lift the gastroesophageal junction to further expose the left crus of the diaphragm. Thus, a \"tunnel\" is successfully created at the lower end of the esophagus (Fig. 1 c). Turn to the front of the esophagogastric junction. Incise the phrenoesophageal ligament on the left side of the esophagogastric junction and connect the \"tunnel\". Further separate to the left along the fundus of the stomach, cut the gastrophrenic ligament until the upper pole of the spleen (Fig. 1 d). Incise the phrenoesophageal ligament on the right side of the esophagogastric junction, complete extensive mobilization of the lower segment of the esophagus and the fundus of the stomach, and further mobilize the lower segment of the esophagus for about 6 cm. Use 2 − 0 non-absorbable sutures for intermittent suturing of the left and right crus of the diaphragm, and reconstruct the esophageal hiatus. Insert biological or synthetic mesh to prevent recurrence. Determine the appropriate fundoplication technique (360° Nissen, 270° Toupet, or 180° Dor) based on the patient's specific condition, and complete the fundoplication surgery (Fig. 2 ). Postoperative Follow-up Follow-ups were conducted at 1, 3, and 6 months postoperatively, through outpatient visits, hospitalization, or telephone calls. The follow-up content included gastroscopy, upper gastrointestinal radiography, quality of life score (GERD-Q score), abdominal ultrasound, and suspected symptoms of vagus nerve injury (such as diarrhea, nausea, vomiting, belching, abdominal distension, etc.). Statistical Analysis Descriptive statistical analysis was performed on all variables. Normally distributed continuous variables are expressed as mean (± SD), non-normally distributed continuous variables as median and interquartile range. Categorical variables are summarized as proportions. Differences between categorical variables were assessed using χ² test, differences between continuous variables using analysis of variance, and non-normally distributed data using Kruskal-Wallis test. All statistical analyses were conducted using R Studio (version 4.3.3, USA). Statistical significance was defined as a two-sided p-value less than 0.05. Results A total of 106 patients underwent Laparoscopic \"Tunnel\" Approach for the treatment of hiatal hernia combined with gastroesophageal reflux disease. There were 65 females and 41 males, with an average age of 54 ± 9 years, average height of 165 ± 6 cm, average weight of 69.4 ± 9.9 kg, and average BMI of 25.56 ± 4.32 kg/m² (Table 1 ). The average DeMeester score was 118.05 ± 17.71, and the average GERD-Q score was 13 ± 2. All patients underwent fundoplication surgery, and the main trunk of the vagus nerve and its hepatic branches were avoided during the operation. The average surgical time was 115 ± 15 minutes. Table 1 Demographic Characteristics N = 106 Age (years) 54 ± 9 Sex Male 41 (38.7%) Female 65 (61.3%) Height (cm) 165 ± 6 Weight (kg) 69.4 ± 9.9 BMI (kg/m2) 25.56 ± 4.32 Smoking (years) Never or <1 42 (39.6%) 1–10 27 (25.5%) ≥ 10 37 (34.9%) DeMeester score 118.05 ± 17.71 GERD-Q score 13 ± 2 Surgical time (min) 115 ± 15 N=106 indicates that the sample size is 106 patients. Age, height, weight, DeMeester score, and GERD−Q score are presented as mean ± standard deviation. Sex and smoking history are shown as number of cases (percentage). The DeMeester score is used to assess the severity of gastroesophageal reflux disease (GERD), while the GERD−Q score evaluates the patient's quality of life. Surgical time refers to the average duration of the surgery. BMI (Body Mass Index) is an indicator that measures the ratio of weight to height, calculated by dividing weight (kg) by the square of height (m) . Postoperative Conditions The symptoms of all patients were significantly relieved after surgery, with an average GERD-Q score of 5 ± 1 after 6 months. Table 2 delineates the clinical manifestations observed among patients at distinct temporal junctures throughout the follow-up duration. Within the first month of the follow-up phase, dysphagia was manifested in 14 subjects, belching in 19, abdominal distension in 5, nausea in 16, and diarrhea in 8. Importantly, no occurrences of vomiting or gallstones were noted during this initial assessment period. Transitioning to the 3-month follow-up interval, the prevalence of dysphagia was observed in 3 patients, belching in 13, and nausea in 5. At the 6-month follow-up milestone, only two cases exhibited symptoms of belching, with all other patients experiencing a complete resolution of symptoms. In these 2 cases, preoperative esophageal manometry revealed ineffective esophageal motility, making it impossible to determine whether it was caused by vagus nerve injury. Table 2 Incidence of Vagus Nerve Injury-Related Complications Following Surgical Procedures 1 month 3 months 6 months Dysphagia 14 (13.2%) 3 (2.8%) 0 Belching 19 (17.9%) 13 (12.3%) 2 (1.9%) Abdominal Distension 5 (4.7%) 0 0 Nausea 16 (15.1%) 5 (4.7%) 0 Vomiting 0 0 0 Diarrhea 8 (7.5%) 0 0 Gallstones 0 0 0 This table presents the follow−up data at 1 month, 3 months, and 6 months after surgery, with a sample size of 106 patients. The incidence of each symptom is expressed as number of cases (percentage) . Discussion Unlike the treatment of malignant tumors, the treatment of benign diseases (such as hiatal hernia and gastroesophageal reflux disease) not only aims to achieve surgical efficacy but also to minimize collateral damage and maintain the patient's current quality of life. Protection of the vagus nerve is particularly important[ 12 ]. The left and right vagus nerves descend to the anterior and posterior surfaces of the ventral esophagus, respectively. The anterior trunk gives off the gastric anterior branch and hepatic branch in front of the cardia, while the posterior trunk gives off the gastric posterior branch and abdominal branch behind the cardia. The hepatic branch of the anterior vagus nerve joins the gastric anterior branch at the foot and runs along the lower edge of the left lobe of the liver. The hepatic branch runs to the right along the upper part of the lesser omentum, and its terminal branches are mainly distributed in the liver and bile ducts, closely related to gallbladder contraction and bile secretion[ 13 – 15 ]. The pyloric branch originates from the hepatic branch, descends backward, and runs down along the hepatoduodenal ligament to innervate the pyloric area. The abdominal branch is widely distributed in the upper digestive tract organs such as the stomach, duodenum, jejunum, and pancreas, playing an important regulatory role in gastrointestinal motility and intestinal secretion[ 16 – 18 ]. The anterior and posterior branches of the stomach run along the lesser curvature of the stomach and are distributed on the anterior and posterior walls of the stomach. Their terminal branches enter the antrum of the stomach in a \"claw\" shape, controlling gastric motility, gastric secretion, and pyloric emptying[ 19 , 20 ]. Hashimoto et al. found that the hepatic branch of the vagus nerve plays an important role in lipid regulation in mice[ 21 ]. López-Soldado et al. found that the regulation of hepatic glycogen depends on the hepatic branch of the vagus nerve, affecting food intake and glucose homeostasis[ 22 ]. Studies have confirmed that preserving the ventral branch of the vagus nerve can significantly improve postoperative gastrointestinal motility in patients with hiatal hernia and reduce the incidence of gastroparesis[ 6 , 23 ]. Given the crucial roles these nerve branches play in gastrointestinal and biliary physiology, preserving the corresponding regional blood supply and nerve innervation is a necessary requirement for maintaining the patient's postoperative quality of life. Protecting the short gastric vessels is also key to ensuring postoperative gastric function. These vessels maintain the blood supply and function of the corresponding gastric wall. Ligation of the short gastric vessels can affect the blood supply, peristalsis, and secretory function of the corresponding gastric wall to a certain extent, leading to delayed gastric emptying and functional recovery. It can also increase the risk of surgical bleeding and infection[ 24 ]. It has been reported that extensive dissection of the short gastric vessels in surgeries such as laparoscopic sleeve gastrectomy often leads to bleeding due to separation of these vessels and sutures[ 25 , 26 ]. Based on the significance of the vagus nerve and short gastric vessels, we observed that a thin layer of visceral peritoneum covers between the hepatogastric ligament and the lesser curvature of the stomach, lacking blood vessels, nerves, and adipose tissue, serving as the boundary between various ligaments. Laparoscopic repair of hiatal hernia combined with fundoplication through stripping the boundary area free of blood vessels, nerves, and fat can maximally protect the main trunk of the vagus nerve and its branches while preserving the short gastric vessels. Through retrospective analysis, we confirmed the feasibility of this method. At the 6-month follow-up post-surgery, only 2 patients exhibited symptoms of hiccups, a proportion significantly lower than that reported in other studies. In clinical practice, the inability to directly measure or assess abdominal vagus nerve function and the lack of intraoperative monitoring are noteworthy facts. Therefore, the incidence of vagus nerve dysfunction after anti-reflux surgery is based on feedback from symptoms such as diarrhea, nausea, and vomiting. Studies have developed an indirect method to measure vagus nerve function, namely the insulin hypoglycemia-pancreatic polypeptide (IH-PP) test, by measuring the secretion of plasma pancreatic polypeptide (PP) during insulin-induced hypoglycemia[ 5 , 27 , 28 ]. Moreover, the use of claw-shaped stimulating electrodes has successfully achieved intraoperative monitoring of vagus nerve abdominal branch stimulation signals, suggesting that intraoperative neurophysiological examination is a feasible method for monitoring the vagus nerve around the stomach[ 29 ]. These studies provide more effective means for future monitoring and protection of the vagus nerve and offer new directions for the protection of the vagus nerve during surgery. Conclusions It cannot be denied that compared with other surgical approaches, the laparoscopic \"tunnel\" approach benefits from a more comprehensive anatomical theoretical basis. Compared with the traditional surgical approach, the laparoscopic \"tunnel\" approach can better avoid the vagus nerve injury. In the surgical treatment of functional diseases, the necessity of preserving function while reconstructing function is unquestionable. This study will provide important data for future research iterations. It is hoped that more research centers and patients will be recruited to develop more precise treatment methods for hiatal hernia and to perfect more precise surgical models. The goal is to improve the short-term and long-term treatment outcomes for patients with gastroesophageal reflux disease and hiatal hernia. Declarations Ethics approval and consent to participate: The present study was approved by the Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 2025-024RS). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Acknowledgments: We thank all the members of the Department of Gastrointestinal Surgery, the First Affiliated Hospital of Ningbo University for their technical support. world Funding: This research was funded by Application of NRS2002 in nutritional management of elderly patients after discharge from general surgery under the mode of medical alliance, Ningbo Science and Technology Bureau, grant number 2022S076. Author Contributions: Conceptualization, Zhewen Feng and Zhiping Zhang.; methodology, Zhewen Feng; software, Zhewen Feng; validation, Zhewen Feng; formal analysis, Zhewen Feng; investigation, Zhewen Feng; resources, Zhewen Feng; data curation, Zhewen Feng; writing—original draft preparation, Zhewen Feng; writing—review and editing, Zhewen Feng; visualization, Zhewen Feng; supervision, Feng Gao and Zhilong Yan; project administration, Qingfeng Chen; funding acquisition, Qingfeng Chen. All authors have read and agreed to the published version of the manuscript. Conflicts of Interest: The authors declare no conflicts of interest. References Philpott H, Sweis R. Hiatus Hernia as a Cause of Dysphagia[J]. Curr Gastroenterol Rep. 2017;19(8):40. Dallemagne B, Perretta S. Twenty years of laparoscopic fundoplication for GERD[J]. World J Surg. 2011;35(7):1428–35. Wang YR, Dempsey DT, Richter JE. Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993–2006[J]. Dis Esophagus. 2011;24(4):215–23. Kessing BF, Broeders JA, Vinke N, et al. Gas-related symptoms after antireflux surgery[J]. Surg Endosc. 2013;27(10):3739–47. van Rijn S, Rinsma NF, van Herwaarden-Lindeboom MY, et al. Effect of Vagus Nerve Integrity on Short and Long-Term Efficacy of Antireflux Surgery[J]. Am J Gastroenterol. 2016;111(4):508–15. Jamieson GG, Maddern GJ, Myers JC. Gastric emptying after fundoplication with and without proximal gastric vagotomy[J]. Arch Surg. 1991;126(11):1414–7. Straathof JW, Ringers J, Masclee AA. Prospective study of the effect of laparoscopic Nissen fundoplication on reflux mechanisms[J]. Br J Surg. 2001;88(11):1519–24. DeVault KR, Swain JM, Wentling GK, et al. Evaluation of vagus nerve function before and after antireflux surgery[J]. J Gastrointest Surg. 2004;8(7):883–8. discussion 888-9. Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia[J]. Surg Endosc. 2013;27(12):4409–28. Zheng Z, Zhang W, Xin C, et al. Laparoscopic total left-sided surgical approach versus traditional bilateral surgical approach for treating hiatal hernia: a study protocol for a randomized controlled trial[J]. Ann Transl Med. 2021;9(11):951. Zheng Z, Liu X, Xin C, et al. A new technique for treating hiatal hernia with gastroesophageal reflux disease: the laparoscopic total left-side surgical approach[J]. BMC Surg. 2021;21(1):361. Nomura E, Okajima K. Function-preserving gastrectomy for gastric cancer in Japan[J]. World J Gastroenterol. 2016;22(26):5888–95. Tomita R. 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A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease[J]. Am J Surg. 2014;207(1):120–6. Gourcerol G, Benanni Y, Boueyre E, et al. Influence of gastric emptying on gastro-esophageal reflux: a combined pH-impedance study[J]. Neurogastroenterol Motil. 2013;25(10):800–e800634. Rebecchi F, Allaix ME, Giaccone C, et al. Gastric emptying as a prognostic factor for long-term results of total laparoscopic fundoplication for weakly acidic or mixed reflux[J]. Ann Surg. 2013;258(5):831–6. discussion 836-7. Hashimoto N, Nagata R, Han KH, et al. Involvement of the vagus nerve and hepatic gene expression in serum adiponectin concentrations in mice[J]. J Physiol Biochem. 2024;80(1):99–112. López-Soldado I, Fuentes-Romero R, Duran J, et al. Effects of hepatic glycogen on food intake and glucose homeostasis are mediated by the vagus nerve in mice[J]. Diabetologia. 2017;60(6):1076–83. Cockbain AJ, Parameswaran R, Watson DI, et al. Flatulence After Anti-reflux Treatment (FAART) Study[J]. World J Surg. 2019;43(12):3065–73. Salminen P, Grönroos S, Helmiö M, et al. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial[J]. JAMA Surg. 2022;157(8):656–66. Wawrzyniak A, Krotki M. The Need and Safety of Mineral Supplementation in Adults with Obesity Post Bariatric Surgery-Sleeve Gastrectomy (SG)[J]. Obes Surg. 2021;31(10):4502–10. Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity[J]. Ann Surg. 2000;232(4):515–29. Lindeboom MY, Ringers J, van Rijn PJ, et al. Gastric emptying and vagus nerve function after laparoscopic partial fundoplication[J]. Ann Surg. 2004;240(5):785–90. Schwartz TW. Pancreatic polypeptide: a hormone under vagal control[J]. Gastroenterology. 1983;85(6):1411–25. Kong SH, Kim SM, Kim DG, et al. Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy[J]. J Gastric Cancer. 2019;19(1):49–61. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 28 Feb, 2025 Editor assigned by journal 27 Feb, 2025 Submission checks completed at journal 27 Feb, 2025 First submitted to journal 16 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6041499\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":422352809,\"identity\":\"c04ef677-0540-4823-8c9c-d81cb90c319f\",\"order_by\":0,\"name\":\"Zhewen Feng\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Ningbo University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zhewen\",\"middleName\":\"\",\"lastName\":\"Feng\",\"suffix\":\"\"},{\"id\":422352810,\"identity\":\"644863ea-3613-4362-a5fd-96e24426d5d8\",\"order_by\":1,\"name\":\"Zhiping Zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Ningbo University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zhiping\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":422352811,\"identity\":\"24c7d2a7-08e8-4c27-b07a-1173771d7626\",\"order_by\":2,\"name\":\"Zhilong Yan\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Ningbo University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zhilong\",\"middleName\":\"\",\"lastName\":\"Yan\",\"suffix\":\"\"},{\"id\":422352812,\"identity\":\"00bc2e95-8970-4ef7-a887-ea9dfaa7c585\",\"order_by\":3,\"name\":\"Feng Gao\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Ningbo University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Feng\",\"middleName\":\"\",\"lastName\":\"Gao\",\"suffix\":\"\"},{\"id\":422352813,\"identity\":\"500f94b1-a660-4e3a-b178-964b287d610b\",\"order_by\":4,\"name\":\"Qingfeng Chen\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxklEQVRIiWNgGAWjYFACxocPEgwkePjZGxsffCBOC7OxwYcKGznJnsPNhjOI1GImOeNMmrHBjfQ2aQ5iNPC3JzNI87YdTpw582GDNAODnZxuAwEtEmceMxiDtPRLJzYYFzAkG5sdIKDFQCL/QDLYltmJDckzGA4kbiOsJZnhMEjLhpsHGw7zEKmFsRHifcbGZqK0AP3CzAAJ5MRmxhkGRPgFGGLsPyBRefz5jw8VdnIEtTAwJKC4k6ByDC2jYBSMglEwCrAAAFK1R3LmfSaEAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Ningbo University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Qingfeng\",\"middleName\":\"\",\"lastName\":\"Chen\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-02-16 13:53:26\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-6041499/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-6041499/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1186/s12893-025-02900-1\",\"type\":\"published\",\"date\":\"2025-04-11T16:05:54+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":78230985,\"identity\":\"4289c12d-3b45-4891-b314-6df6609ddc89\",\"added_by\":\"auto\",\"created_at\":\"2025-03-11 07:33:21\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":573571,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eProcedure of laparoscopic \\\"tunnel\\\" surgical approach. (a) Expose the hepatogastric ligament at the lesser curvature of the stomach. Incise an area on the hepatogastric ligament that is free of blood vessels, nerves, and adipose tissue. Anatomically, this area is devoid of nerve passage. (b) Incise the peritoneum at the outer edge of the right crus of the diaphragm, and bluntly dissect the loose tissue at the lower end of the esophagus to expose the junction of the left and right crus of the diaphragm. (c) Lift the gastroesophageal junction to further expose the left crus of the diaphragm. Thus, a \\\"tunnel\\\" is successfully created at the lower end of the esophagus. (d) Incise the phrenoesophageal ligament on the left side of the esophagogastric junction and connect the \\\"tunnel\\\". Further separate to the left along the fundus of the stomach, cut the gastrophrenic ligament until the upper pole of the spleen.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6041499/v1/4d75b4c067dc42e89079d7c7.png\"},{\"id\":78231029,\"identity\":\"f37bb740-257a-4a03-b883-f00f7892d738\",\"added_by\":\"auto\",\"created_at\":\"2025-03-11 07:33:36\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":374685,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eHiatal hernia repair and fundoplication.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6041499/v1/2bb324a188bfc3af4c7ff87e.png\"},{\"id\":80559136,\"identity\":\"899476a1-dd92-4cd3-8a36-bbf8750579df\",\"added_by\":\"auto\",\"created_at\":\"2025-04-14 16:17:57\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1448579,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6041499/v1/d01ca8d4-a9df-42c3-9e21-1d65c135d26c.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Innovative Laparoscopic 'Tunnel' Approach in Managing Hiatal Hernia with gastroesophageal reflux disease: A Retrospective Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eHiatal hernia (HH) refers to the condition where abdominal contents enter the thoracic cavity through the esophageal hiatus of the diaphragm and is considered a primary cause of gastroesophageal reflux disease (GERD)[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. Laparoscopic repair of HH combined with anti-reflux surgery is suitable for patients with chronic symptoms of HH and GERD, those who are refractory to proton pump inhibitors (PPI), or those unwilling to take PPIs for life.\\u003c/p\\u003e \\u003cp\\u003eThe treatment goal for HH combined with GERD is to achieve optimal long-term control of reflux symptoms and signs with minimal or no side effects. Despite continuous improvements in surgical techniques[\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e], postoperative complications still occur[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]. Vagus nerve injury is a common complication of laparoscopic HH repair combined with fundoplication[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]. Studies have shown that approximately 10\\u0026ndash;20% of GERD patients experience vagus nerve injury after anti-reflux surgery[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]. Vagus nerve injury can lead to postoperative symptoms such as diarrhea, nausea, vomiting, gastric emptying disorders, belching, and abdominal bloating, and can also increase the incidence of gallstones[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. In 20-year follow-up data, patients with vagus nerve injury had significantly worse outcomes in terms of gastroesophageal reflux symptoms, satisfaction rates, and reoperation rates[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe traditional bilateral surgical approach (TBSA) is the main surgical method for laparoscopic HH repair combined with fundoplication[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]. A disadvantage of TBSA is that although it can provide local protection of the vagus nerve during surgery, it cannot assess the integrity of the vagus nerve, potentially causing undetected nerve damage[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. Other surgical approaches, such as the total left-sided approach (TLSA), can effectively avoid iatrogenic damage to the main trunk of the vagus nerve and its hepatic branches[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]. However, TLSA requires incision of the gastrocolic ligament, inevitably splitting some short gastric and gastroepiploic vessels, restricting the venous blood flow around the stomach, and increasing the risk of gastric emptying disorders. Moreover, the ligation of short gastric vessels poses a potential hazard for preserving the proximal stomach in subsequent gastric surgeries.\\u003c/p\\u003e \\u003cp\\u003eTherefore, based on the existing surgical defects, our center innovatively proposes a new surgical approach\\u0026mdash;the Laparoscopic \\\"Tunnel\\\" Approach. The potential advantages of this method are that it not only minimizes damage to the main trunk of the vagus nerve and its hepatic branches but also preserves all perigastric vessels, such as the short gastric vessels.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003eA retrospective analysis was conducted on patients who underwent laparoscopic \\\"tunnel\\\" approach for the treatment of hiatal hernia combined with gastroesophageal reflux disease at the First Affiliated Hospital of Ningbo University from June 2023 to June 2024. Inclusion criteria: 1) Patients with a definitive diagnosis of gastroesophageal reflux disease; 2) Age 25\\u0026ndash;80 years; patients and their families have good compliance and can cooperate with the treatment; 3) No severe diseases of important organs such as heart, brain, and lungs; 4) No patients with severe anxiety or depression; 5) Meet the surgical indications. Exclusion criteria: 1) Change of surgical method due to special circumstances during surgery; 2) Loss to follow-up, accidental events, or severe somatic diseases.\\u003c/p\\u003e \\u003cp\\u003eSurgical indications: 1) Major complications of hiatal hernia or gastroesophageal reflux disease, such as severe esophagitis, Barrett's esophagus, etc. 2) Patients who have undergone full and systematic drug therapy for more than half a year but still cannot alleviate and eliminate the complications of reflux disease. 3) Patients who have undergone Heller myotomy for esophageal motility disorders to prevent recurrence of gastroesophageal reflux. 4) Patients whose recurrent laryngeal and pulmonary diseases are determined to be caused by reflux disease, as well as those with asthma caused by reflux disease. 5) Patients who have relapsed after surgery and have severe reflux symptoms, or patients with paraesophageal hernia with reflux symptoms that are not successfully treated with drugs. 6) Patients with severe atypia or cancerous changes in pathological examination of cells.\\u003c/p\\u003e \\u003cp\\u003e All patients signed an informed consent form before surgery. The collected clinical data included: age, gender, height, weight, BMI, DeMeester score, hiatal hernia classification, quality of life score (GERD-Q score), surgical time, blood loss, etc. The present study was approved by the Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 2025-024RS). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e \\u003cp\\u003e \\u003cb\\u003eLaparoscopic \\\"Tunnel\\\" Surgical Approach Steps\\u003c/b\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003col\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eExpose the hepatogastric ligament at the lesser curvature of the stomach. Incise an area on the hepatogastric ligament that is free of blood vessels, nerves, and adipose tissue. Anatomically, this area is devoid of nerve passage (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003ea).\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eIncise the peritoneum at the outer edge of the right crus of the diaphragm, and bluntly dissect the loose tissue at the lower end of the esophagus to expose the junction of the left and right crus of the diaphragm (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eb). Lift the gastroesophageal junction to further expose the left crus of the diaphragm. Thus, a \\\"tunnel\\\" is successfully created at the lower end of the esophagus (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003ec).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eTurn to the front of the esophagogastric junction. Incise the phrenoesophageal ligament on the left side of the esophagogastric junction and connect the \\\"tunnel\\\". Further separate to the left along the fundus of the stomach, cut the gastrophrenic ligament until the upper pole of the spleen (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003ed). Incise the phrenoesophageal ligament on the right side of the esophagogastric junction, complete extensive mobilization of the lower segment of the esophagus and the fundus of the stomach, and further mobilize the lower segment of the esophagus for about 6 cm.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eUse 2\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 non-absorbable sutures for intermittent suturing of the left and right crus of the diaphragm, and reconstruct the esophageal hiatus. Insert biological or synthetic mesh to prevent recurrence.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003cspan\\u003e \\u003cli\\u003e \\u003cp\\u003eDetermine the appropriate fundoplication technique (360\\u0026deg; Nissen, 270\\u0026deg; Toupet, or 180\\u0026deg; Dor) based on the patient's specific condition, and complete the fundoplication surgery (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/span\\u003e \\u003c/ol\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePostoperative Follow-up\\u003c/h2\\u003e \\u003cp\\u003eFollow-ups were conducted at 1, 3, and 6 months postoperatively, through outpatient visits, hospitalization, or telephone calls. The follow-up content included gastroscopy, upper gastrointestinal radiography, quality of life score (GERD-Q score), abdominal ultrasound, and suspected symptoms of vagus nerve injury (such as diarrhea, nausea, vomiting, belching, abdominal distension, etc.).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003eDescriptive statistical analysis was performed on all variables. Normally distributed continuous variables are expressed as mean (\\u0026plusmn;\\u0026thinsp;SD), non-normally distributed continuous variables as median and interquartile range. Categorical variables are summarized as proportions. Differences between categorical variables were assessed using χ\\u0026sup2; test, differences between continuous variables using analysis of variance, and non-normally distributed data using Kruskal-Wallis test. All statistical analyses were conducted using R Studio (version 4.3.3, USA). Statistical significance was defined as a two-sided p-value less than 0.05.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA total of 106 patients underwent Laparoscopic \\\"Tunnel\\\" Approach for the treatment of hiatal hernia combined with gastroesophageal reflux disease. There were 65 females and 41 males, with an average age of 54\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9 years, average height of 165\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6 cm, average weight of 69.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.9 kg, and average BMI of 25.56\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.32 kg/m\\u0026sup2; (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). The average DeMeester score was 118.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;17.71, and the average GERD-Q score was 13\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2. All patients underwent fundoplication surgery, and the main trunk of the vagus nerve and its hepatic branches were avoided during the operation. The average surgical time was 115\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15 minutes.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDemographic Characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"2\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eN\\u0026thinsp;=\\u0026thinsp;106\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e54\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e41 (38.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e65 (61.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHeight (cm)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e165\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;6\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eWeight (kg)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e69.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBMI (kg/m2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e25.56\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.32\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoking (years)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNever or \\u0026lt;1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e42 (39.6%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e1\\u0026ndash;10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e27 (25.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u0026ge;\\u0026thinsp;10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e37 (34.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDeMeester score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e118.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;17.71\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGERD-Q score\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSurgical time (min)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e115\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"2\\\"\\u003e\\u003csup\\u003eN=106 indicates that the sample size is 106 patients. Age, height, weight, DeMeester score, and GERD\\u0026minus;Q score are presented as mean \\u0026plusmn; standard deviation. Sex and smoking history are shown as number of cases (percentage). The DeMeester score is used to assess the severity of gastroesophageal reflux disease (GERD), while the GERD\\u0026minus;Q score evaluates the patient's quality of life. Surgical time refers to the average duration of the surgery. BMI (Body Mass Index) is an indicator that measures the ratio of weight to height, calculated by dividing weight (kg) by the square of height (m)\\u003c/sup\\u003e.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003ePostoperative Conditions\\u003c/h3\\u003e\\n\\u003cp\\u003eThe symptoms of all patients were significantly relieved after surgery, with an average GERD-Q score of 5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1 after 6 months. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e delineates the clinical manifestations observed among patients at distinct temporal junctures throughout the follow-up duration. Within the first month of the follow-up phase, dysphagia was manifested in 14 subjects, belching in 19, abdominal distension in 5, nausea in 16, and diarrhea in 8. Importantly, no occurrences of vomiting or gallstones were noted during this initial assessment period. Transitioning to the 3-month follow-up interval, the prevalence of dysphagia was observed in 3 patients, belching in 13, and nausea in 5. At the 6-month follow-up milestone, only two cases exhibited symptoms of belching, with all other patients experiencing a complete resolution of symptoms. In these 2 cases, preoperative esophageal manometry revealed ineffective esophageal motility, making it impossible to determine whether it was caused by vagus nerve injury.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eIncidence of Vagus Nerve Injury-Related Complications Following Surgical Procedures\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e1 month\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 months\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e6 months\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDysphagia\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14 (13.2%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3 (2.8%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBelching\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e19 (17.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13 (12.3%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2 (1.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAbdominal Distension\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5 (4.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNausea\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e16 (15.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5 (4.7%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVomiting\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDiarrhea\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8 (7.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGallstones\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003e\\u003csup\\u003eThis table presents the follow\\u0026minus;up data at 1 month, 3 months, and 6 months after surgery, with a sample size of 106 patients. The incidence of each symptom is expressed as number of cases (percentage)\\u003c/sup\\u003e.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eUnlike the treatment of malignant tumors, the treatment of benign diseases (such as hiatal hernia and gastroesophageal reflux disease) not only aims to achieve surgical efficacy but also to minimize collateral damage and maintain the patient's current quality of life. Protection of the vagus nerve is particularly important[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e]. The left and right vagus nerves descend to the anterior and posterior surfaces of the ventral esophagus, respectively. The anterior trunk gives off the gastric anterior branch and hepatic branch in front of the cardia, while the posterior trunk gives off the gastric posterior branch and abdominal branch behind the cardia. The hepatic branch of the anterior vagus nerve joins the gastric anterior branch at the foot and runs along the lower edge of the left lobe of the liver. The hepatic branch runs to the right along the upper part of the lesser omentum, and its terminal branches are mainly distributed in the liver and bile ducts, closely related to gallbladder contraction and bile secretion[\\u003cspan additionalcitationids=\\\"CR14\\\" citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e]. The pyloric branch originates from the hepatic branch, descends backward, and runs down along the hepatoduodenal ligament to innervate the pyloric area. The abdominal branch is widely distributed in the upper digestive tract organs such as the stomach, duodenum, jejunum, and pancreas, playing an important regulatory role in gastrointestinal motility and intestinal secretion[\\u003cspan additionalcitationids=\\\"CR17\\\" citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]. The anterior and posterior branches of the stomach run along the lesser curvature of the stomach and are distributed on the anterior and posterior walls of the stomach. Their terminal branches enter the antrum of the stomach in a \\\"claw\\\" shape, controlling gastric motility, gastric secretion, and pyloric emptying[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e]. Hashimoto et al. found that the hepatic branch of the vagus nerve plays an important role in lipid regulation in mice[\\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. L\\u0026oacute;pez-Soldado et al. found that the regulation of hepatic glycogen depends on the hepatic branch of the vagus nerve, affecting food intake and glucose homeostasis[\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Studies have confirmed that preserving the ventral branch of the vagus nerve can significantly improve postoperative gastrointestinal motility in patients with hiatal hernia and reduce the incidence of gastroparesis[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. Given the crucial roles these nerve branches play in gastrointestinal and biliary physiology, preserving the corresponding regional blood supply and nerve innervation is a necessary requirement for maintaining the patient's postoperative quality of life.\\u003c/p\\u003e \\u003cp\\u003eProtecting the short gastric vessels is also key to ensuring postoperative gastric function. These vessels maintain the blood supply and function of the corresponding gastric wall. Ligation of the short gastric vessels can affect the blood supply, peristalsis, and secretory function of the corresponding gastric wall to a certain extent, leading to delayed gastric emptying and functional recovery. It can also increase the risk of surgical bleeding and infection[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e]. It has been reported that extensive dissection of the short gastric vessels in surgeries such as laparoscopic sleeve gastrectomy often leads to bleeding due to separation of these vessels and sutures[\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eBased on the significance of the vagus nerve and short gastric vessels, we observed that a thin layer of visceral peritoneum covers between the hepatogastric ligament and the lesser curvature of the stomach, lacking blood vessels, nerves, and adipose tissue, serving as the boundary between various ligaments. Laparoscopic repair of hiatal hernia combined with fundoplication through stripping the boundary area free of blood vessels, nerves, and fat can maximally protect the main trunk of the vagus nerve and its branches while preserving the short gastric vessels. Through retrospective analysis, we confirmed the feasibility of this method. At the 6-month follow-up post-surgery, only 2 patients exhibited symptoms of hiccups, a proportion significantly lower than that reported in other studies.\\u003c/p\\u003e \\u003cp\\u003eIn clinical practice, the inability to directly measure or assess abdominal vagus nerve function and the lack of intraoperative monitoring are noteworthy facts. Therefore, the incidence of vagus nerve dysfunction after anti-reflux surgery is based on feedback from symptoms such as diarrhea, nausea, and vomiting. Studies have developed an indirect method to measure vagus nerve function, namely the insulin hypoglycemia-pancreatic polypeptide (IH-PP) test, by measuring the secretion of plasma pancreatic polypeptide (PP) during insulin-induced hypoglycemia[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. Moreover, the use of claw-shaped stimulating electrodes has successfully achieved intraoperative monitoring of vagus nerve abdominal branch stimulation signals, suggesting that intraoperative neurophysiological examination is a feasible method for monitoring the vagus nerve around the stomach[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. These studies provide more effective means for future monitoring and protection of the vagus nerve and offer new directions for the protection of the vagus nerve during surgery.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eIt cannot be denied that compared with other surgical approaches, the laparoscopic \\\"tunnel\\\" approach benefits from a more comprehensive anatomical theoretical basis. Compared with the traditional surgical approach, the laparoscopic \\\"tunnel\\\" approach can better avoid the vagus nerve injury. In the surgical treatment of functional diseases, the necessity of preserving function while reconstructing function is unquestionable. This study will provide important data for future research iterations. It is hoped that more research centers and patients will be recruited to develop more precise treatment methods for hiatal hernia and to perfect more precise surgical models. The goal is to improve the short-term and long-term treatment outcomes for patients with gastroesophageal reflux disease and hiatal hernia.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate:\\u003c/strong\\u003e The present study was approved by the Ethics Committee of the First Affiliated Hospital of Ningbo University (Approval No. 2025-024RS). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgments:\\u0026nbsp;\\u003c/strong\\u003eWe thank all the members of the Department of Gastrointestinal Surgery, the First Affiliated Hospital of Ningbo University for their technical support.\\u003c/p\\u003e\\n\\u003cp\\u003eworld\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding:\\u003c/strong\\u003e This research was funded by Application of NRS2002 in nutritional management of elderly patients after discharge from general surgery under the mode of medical alliance, Ningbo Science and Technology Bureau, grant number 2022S076.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor Contributions:\\u003c/strong\\u003e Conceptualization, Zhewen Feng and Zhiping Zhang.; methodology, Zhewen Feng; software, Zhewen Feng; validation, Zhewen Feng; formal analysis, Zhewen Feng; investigation, Zhewen Feng; resources, Zhewen Feng; data curation, Zhewen Feng; writing—original draft preparation, Zhewen Feng; writing—review and editing, Zhewen Feng; visualization, Zhewen Feng; supervision, Feng Gao and Zhilong Yan; project administration, Qingfeng Chen; funding acquisition, Qingfeng Chen. All authors have read and agreed to the published version of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflicts of Interest:\\u003c/strong\\u003e The authors declare no conflicts of interest.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePhilpott H, Sweis R. Hiatus Hernia as a Cause of Dysphagia[J]. Curr Gastroenterol Rep. 2017;19(8):40.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDallemagne B, Perretta S. Twenty years of laparoscopic fundoplication for GERD[J]. World J Surg. 2011;35(7):1428\\u0026ndash;35.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eWang YR, Dempsey DT, Richter JE. Trends and perioperative outcomes of inpatient antireflux surgery in the United States, 1993\\u0026ndash;2006[J]. Dis Esophagus. 2011;24(4):215\\u0026ndash;23.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKessing BF, Broeders JA, Vinke N, et al. Gas-related symptoms after antireflux surgery[J]. Surg Endosc. 2013;27(10):3739\\u0026ndash;47.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003evan Rijn S, Rinsma NF, van Herwaarden-Lindeboom MY, et al. Effect of Vagus Nerve Integrity on Short and Long-Term Efficacy of Antireflux Surgery[J]. Am J Gastroenterol. 2016;111(4):508\\u0026ndash;15.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eJamieson GG, Maddern GJ, Myers JC. Gastric emptying after fundoplication with and without proximal gastric vagotomy[J]. Arch Surg. 1991;126(11):1414\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eStraathof JW, Ringers J, Masclee AA. Prospective study of the effect of laparoscopic Nissen fundoplication on reflux mechanisms[J]. Br J Surg. 2001;88(11):1519\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDeVault KR, Swain JM, Wentling GK, et al. Evaluation of vagus nerve function before and after antireflux surgery[J]. J Gastrointest Surg. 2004;8(7):883\\u0026ndash;8. discussion 888-9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia[J]. Surg Endosc. 2013;27(12):4409\\u0026ndash;28.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZheng Z, Zhang W, Xin C, et al. Laparoscopic total left-sided surgical approach versus traditional bilateral surgical approach for treating hiatal hernia: a study protocol for a randomized controlled trial[J]. Ann Transl Med. 2021;9(11):951.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZheng Z, Liu X, Xin C, et al. A new technique for treating hiatal hernia with gastroesophageal reflux disease: the laparoscopic total left-side surgical approach[J]. BMC Surg. 2021;21(1):361.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNomura E, Okajima K. Function-preserving gastrectomy for gastric cancer in Japan[J]. World J Gastroenterol. 2016;22(26):5888\\u0026ndash;95.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTomita R. Gastric emptying function in patients 5 years after pylorus-preserving distal gastrectomy with or without preserving pyloric and hepatic branches of the vagal nerve for early gastric cancer[J]. World J Surg. 2009;33(10):2119\\u0026ndash;26.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEom BW, Park B, Yoon HM, et al. Laparoscopy-assisted pylorus-preserving gastrectomy for early gastric cancer: A retrospective study of long-term functional outcomes and quality of life[J]. World J Gastroenterol. 2019;25(36):5494\\u0026ndash;504.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eZhu CC, Cao H, Berlth F, et al. Pylorus-preserving gastrectomy for early cancer involving the upper third: can we go higher?[J]. Gastric Cancer. 2019;22(4):881\\u0026ndash;91.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCamilleri M, Parkman HP, Shafi MA, et al. Clinical guideline: management of gastroparesis[J]. Am J Gastroenterol. 2013;108(1):18\\u0026ndash;37. quiz 38.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMiyano Y, Sakata I, Kuroda K, et al. The role of the vagus nerve in the migrating motor complex and ghrelin- and motilin-induced gastric contraction in suncus[J]. PLoS ONE. 2013;8(5):e64777.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLagoo J, Pappas TN, Perez A. A relic or still relevant: the narrowing role for vagotomy in the treatment of peptic ulcer disease[J]. Am J Surg. 2014;207(1):120\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGourcerol G, Benanni Y, Boueyre E, et al. Influence of gastric emptying on gastro-esophageal reflux: a combined pH-impedance study[J]. Neurogastroenterol Motil. 2013;25(10):800\\u0026ndash;e800634.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRebecchi F, Allaix ME, Giaccone C, et al. Gastric emptying as a prognostic factor for long-term results of total laparoscopic fundoplication for weakly acidic or mixed reflux[J]. Ann Surg. 2013;258(5):831\\u0026ndash;6. discussion 836-7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHashimoto N, Nagata R, Han KH, et al. Involvement of the vagus nerve and hepatic gene expression in serum adiponectin concentrations in mice[J]. J Physiol Biochem. 2024;80(1):99\\u0026ndash;112.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eL\\u0026oacute;pez-Soldado I, Fuentes-Romero R, Duran J, et al. Effects of hepatic glycogen on food intake and glucose homeostasis are mediated by the vagus nerve in mice[J]. Diabetologia. 2017;60(6):1076\\u0026ndash;83.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCockbain AJ, Parameswaran R, Watson DI, et al. Flatulence After Anti-reflux Treatment (FAART) Study[J]. World J Surg. 2019;43(12):3065\\u0026ndash;73.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSalminen P, Gr\\u0026ouml;nroos S, Helmi\\u0026ouml; M, et al. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial[J]. 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Gastroenterology. 1983;85(6):1411\\u0026ndash;25.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKong SH, Kim SM, Kim DG, et al. Intraoperative Neurophysiologic Testing of the Perigastric Vagus Nerve Branches to Evaluate Viability and Signals along Nerve Pathways during Gastrectomy[J]. J Gastric Cancer. 2019;19(1):49\\u0026ndash;61.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Hiatal Hernia, gastroesophageal reflux disease, Laparoscopic surgery, Vagus nerve\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6041499/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6041499/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eHiatal hernia (HH) is a major cause of gastroesophageal reflux disease (GERD), and laparoscopic repair combined with anti-reflux surgery is a common treatment. However, postoperative complications such as vagus nerve injury remain a concern. This study introduces a novel Laparoscopic \\\"Tunnel\\\" Approach aiming to minimize damage to the vagus nerve and preserve perigastric vessels.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA retrospective analysis was conducted on 106 patients who underwent the Laparoscopic \\\"Tunnel\\\" Approach for HH and GERD at the First Affiliated Hospital of Ningbo University from June 2023 to June 2024. Data collected included age, gender, BMI, DeMeester score, surgical time, and postoperative symptoms. Follow-ups were conducted at 1, 3, and 6 months postoperatively.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eThe average age was 54\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;9 years, BMI was 25.56\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;4.32 kg/m\\u0026sup2;, DeMeester score was 118.05\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;17.71, and GERD-Q score was 13\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2. The average surgical time was 115\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;15 minutes. Postoperatively, symptoms significantly improved, with an average GERD-Q score of 5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1 at 6 months. At 1 month, dysphagia was observed in 14 patients, belching in 19, abdominal distension in 5, nausea in 16, and diarrhea in 8. By 6 months, only 2 patients exhibited belching, with no other symptoms persisting. No cases of vomiting or gallstones were reported.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eThe Laparoscopic \\\"Tunnel\\\" Approach effectively minimizes vagus nerve injury and preserves perigastric vessels, resulting in improved postoperative outcomes and quality of life. This method shows potential for wider application in treating HH and GERD.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Innovative Laparoscopic 'Tunnel' Approach in Managing Hiatal Hernia with gastroesophageal reflux disease: A Retrospective Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-03-11 07:33:16\",\"doi\":\"10.21203/rs.3.rs-6041499/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-02-28T14:15:23+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-02-27T11:24:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-02-27T11:22:30+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Surgery\",\"date\":\"2025-02-16T13:48:01+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-surgery\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bsur\",\"sideBox\":\"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/bsur/default.aspx\",\"title\":\"BMC Surgery\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"62152d6e-cc73-4354-ba34-5ea6afa4d397\",\"owner\":[],\"postedDate\":\"March 11th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-04-14T16:16:13+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6041499\",\"link\":\"https://doi.org/10.1186/s12893-025-02900-1\",\"journal\":{\"identity\":\"bmc-surgery\",\"isVorOnly\":false,\"title\":\"BMC Surgery\"},\"publishedOn\":\"2025-04-11 16:05:54\",\"publishedOnDateReadable\":\"April 11th, 2025\"},\"versionCreatedAt\":\"2025-03-11 07:33:16\",\"video\":\"\",\"vorDoi\":\"10.1186/s12893-025-02900-1\",\"vorDoiUrl\":\"https://doi.org/10.1186/s12893-025-02900-1\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6041499\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6041499\",\"identity\":\"rs-6041499\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}