Management of Esophageal Hiatus Hernia Syndrome and Associated Abnormalities with Balanced Operations

¹ The Departments of Surgery, Marion County General Hospital and Methodist Hospital.

Hiatal hernia syndrome is due to a malfunction of several of the derivatives of the foregut, as well as a cephalad displacement of the stomach. Therefore, we frequently encounter abnormalities of the esophagus, stomach, duodenum, gallbladder, bile ducts, pancreas, and even the bronchi and lungs.

Most patients with hiatus hernia syndrome may be treated successfully by careful medical management. However, roughly one-fourth will require surgery. These are the patients who have a persistence and progression of symptoms, in spite of adequate medical care, or who have esophageal complications, such as stenosis, bleeding, or perforation, or associated lesions of foregut derivatives.

If surgery is indicated for any of the above reasons, or for unrelated disease, a balanced operation should be done.

The steps of the operation and the reasons for its performance are as follows.

1. The hernia is reduced and prevented from recurring. (Step 3)

2. Bilateral vagotomy is done to reduce the amount of acidity of gastric secretion and to permit more complete descent of the esophagus.

3. The hiatus is repaired by suturing the right crus, imbrecating the sac (in large hernias), and suturing the phrenoesophageal ligament to the crus and the infolded sac to the under surface of the diaphragm.

4. Esophagogastropexy is performed to restore or exaggerate the esophago-gastric angle (angle of HIS) (plic cardiaca).

5. Pyloroplasty is carried out, in which the anterior third of the pylorus is removed, thereby permitting ready egress of gastric contents and relieving intragastric pressure.

6. Associated lesions are corrected.

This procedure has now been done in over 105 patients, with almost uniformly good results. All patients have been followed from six months to nine years, with an average of about four years. We have had only one known recurrence of herniation. No patients have required dilatations or other treatments of the esophagus following the balanced operations.