Henry Ford Hospital Medical Journal Volume 24 | Number 4 Article 7 12-1976 Rationale and results of anatomic repair of esophageal hiatus hernia Conrad R. Lam Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Lam, Conrad R. (1976) "Rationale and results of anatomic repair of esophageal hiatus hernia," Henry Ford Hospital Medical Journal : Vol. 24 : No. 4 , 243-254. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol24/iss4/7 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med Journal Vol 24, No 4,1976 Rationale and results of anatomic repair of esophageal hiatus hernia* Conrad R. Lam, M.D.** A logical method of repair of esophageal /\ logical method for the repair of es- hiatus hernia based on anatomic principles phageal hiatus hernia based on anatomic was proposed nearly 25 years ago by the late principles was proposed nearly 25 years ago Phillip Allison. There was general agreement by the late Philip Allison, then of Leeds and that his operation had advantages, but be­ later of Oxford, England, in his paper titled cause of a disappointing number of recur­ "Reflux Esophagitis, Sliding Hernia and the rences and problems with reflux, more Anatomy of Repair."^ He correctly stressed complicated operations were devised. Some the fact that reflux esophagitis is a complica- of these involved plication of the stomach tion of sliding hernia and not paraesopha­ around the lower esophagus (Nissen, geal hernia, for which he coined the term Belsey). In a series of 562 operations for "rolling hernia." There were two significant hiatus hernia at the Henry Ford Hospital, steps in his "anatomy of repair," (1) the there has been no significant deviation from fixation ofthe phrenoesophageal ligamentto the Allison technic. Compllcadng lower the under surface of the diaphragm with esophageal rings (Schatzki) have been excis­ restoration of the oblique angle of entry of ed. There has been no example of a short the esophagus into the stomach (Figure 1), esophagus which prevented placement of and (2) posterior approximation ofthe crural the stomach below the diaphragm. Residual fibers (Figure 2). He used the transthoracic reflux has not been a problem and the approach, although admittedly his two ob­ recurrence rate has been low (5%). jectives can be attained by a transabdominal approach, as has been done with much success by Hill.^ Although initiallythere was general agree­ ment that the Allison repair was a good one, * Read at the XXVI Congress of the International Surgical Society Edinburgh, Sept 13-18,1975. some surgeons noted a disappointing num­ ber of recurrences and problems with per­ ** Consultant, Division of Thoracic and Cardiac sistent gastroesophageal reflux. As a result, Surgery. there has been a considerable turning away from a basically anatomic repair and a trial Address reprint requests to Dr. Lam at Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, of more complicated procedures aimed at Ml 48202. the creation of a physiologic valve mecha- 243 Lam Figure 1 Drawing from Allison's paper showing attachment of phrenoesophageal ligament to the under surface of the diaphragm through a diaphragmatic incision. (Courtesy of Surgery, Gynecology and Obstetrics). nism by partial or complete wrapping of the tween the years 1947 and 1974. Special stomach around the lower end of the follow-up investigations were made in 345 esophagus. In the operation recommended patients operated on before 1967. 279 of by Ronald Belsey and his associates,^ a fold these (80%) were classified as having sliding ofthe fundus ofthe stomach is sutured to the hernias; 60 (18%) had paraesophageal or anterior two-thirds of the esophagus, rolling hernias, and 6 (2%) were assigned to through a transthoracic approach. In the a new category which has been called "in­ operation of Rudolph Nissen,"the lower end tracardiac bursa hernia" (Figure 3). A com­ ofthe esophagus is completely encircled by plete discussion of the reasons for the the fold of stomach. His preference is for the addition of this new classification can be transabdominal approach. If the simpler found elsewhere.' The infracardiac bursa "anatomic" repair is to be abandoned in hernias are differentiated from other para­ favor ofthose more complicated technics, it esophageal hernias because they enter the must be established that the latter show a chest through an opening to the right of the considerable advantage with long-term fol­ esophagus (the pneumato-enteric recess or low-up. 1 have followed with interest the infracardiac bursa), and invariably come to results of those doing the fundoplication lie in the right pleural cavity. The technic of operations, but 1 have continued to rely on the repair of this type of hernia differs con­ the anatomic repair, basically the technic of siderably from that of the more common Allison. types; some may require an intraabdominal approach. The Henry Ford Hospital series consists of 577 operations on 562 patients, done be­ The technic of repair of sliding and para- 244 Esophageal hiatus hernia Figure 2 Allison's method of ap­ proximation of crural fibers posteriorly. (Re­ produced through cour­ tesy of Surgery, Gynec­ ology and Obstetrics). esophageal hernias which has been used in noesophageal ligament not only may not this series differs only in certain details from cure the reflux, but may aggravate it. that originally described by Allison. The objective is replacement of the esopha­ Because of the large number of dehis­ gogastric junction to a position below the cences which have been reported, there is a diaphragm, but it is not assumed that a disagreement about the advisability of mak­ considerable length of esophagus in the ing the so-called "counter-incision" in the intraabdominal position is either normal or diaphragm which Allison used forthe sutur­ desirable. It is thought that the phre­ ing of the phrenoesophageal ligamentto the noesophageal ligament is an important under surface of the diaphragm (Figure 1). I structure which should be utilized in the have continued to use it in spite of occasion­ repairof hiatus hernia (Figure 4). There have al dehiscences, in the belief that it should be been few anatomic studies of this ligament. possible to close such a simple incision One was by Bombeck, Dillard and Nyhus'' of securely. The method of closure which was the University of Washington who not only evolved involves a double suture line with found the phrenoesophageal ligament in "throws" on each knot of the silk suture every instance in a study of 227 autopsies, (Figure 5). The multiple "throws" are desira­ but concluded that the level of its insertion ble because when repairing the dehis­ on the esophagus appeared to have an effect cences, we found that the sutures had on the competence ofthe lower esophageal become untied ratherthan broken. My asso­ sphincter mechanism. They suggested that ciate. Dr. Thomas Gahagan, used a special an operation which applies circumferential double-needle holder for passingthe sutures tension around the insertion of the phre­ under the diaphragm (Figure 6). The final 245 Lam Several lesions ofthe esophagus may add to the symptoms and complicate the repair of sliding hiatal hernia. Because the esophagus is a thoracic organ, these prob­ lems are dealt with more conveniently when a transthoracic ratherthan a transabdominal approach is chosen for the operation. These lesions are the lower esophageal ring (Schatzki), esophageal stricture, the so- called "short esophagus" and the esophagus lined in part by columnar epithelium (Barrett). In this series of 562 patients with hiatus hernia, 21 (nearly 4%) had a symptomatic Schatzki's ring. These were corrected at the time the hernias were repaired. An example of such a ring is shown in Figure 9. Before reduction ofthe hernia, a small gastrotomy is made and the ring iseasily visualized (Figure 10). It is eliminated either by excision and suture approximation ofthe two mucosas or by a plastic procedure involving 3 or 4 radial incisions. The problem of the lower esophageal ring has been presented in more detail in a previous communication.' For the strictures due to long-standing refluxesophagitis, the method of Hayward of Australia' has been utilized. At the time of the repair of the hernia, there is vigorous Figure 3 dilatation ofthe stricture with the finger and Diagrams of three types of esophageal hiatal instruments introduced through a gastro­ hernia. Figures on the left are frontal views; those tomy, after which the hernia is repaired. on the right are lateral views. A, sliding hernia. B, Additional peroral dilatations are done paraesophageal or rolling hernia. C, infracardiac bursa hernia. (This figure and figures 4-7 are from postoperatively as indicated. Thus, resec­ Gahagan T and Lam CR: Esophageal Hiatus Her­ tion of the strictured portion of esophagus nia: Rationale and Results of Anatomic Repair, and its replacement by colon or a tube of reproduced by courtesy of Charles Thomas, Pub­ stomach have been avoided. lisher, Springfield, IL, 1976.) Much has been said about the "short esophagus" which might make replacement of the stomach into the abdomen impossi­ ble. It has been found that with adequate step in the repair of the hiatus is the approx­ mobilization ofthe "shortened" esophagus, imation of its margins (crural fibers) posteri­ to the arch ofthe aorta if necessary, sufficient orly (Figure 7). It is preferable to tie these length of the esophagus is invariably sutures before the phrenoesophageal liga­ available.'' ment sutures are tied, leaving a finger in the hiatus to prevent an overly tight closure of An example of an apparently short the hiatus (Figure 8).