Incidence And Importance Of The Hiatal Hernia Problem

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Although its exact prevalence in the normal population remains unknown, it is certain that hiatal hernia is the most common abnormality, reported on barium studies of the upper gastrointestinal tract. Women are more likely to be afflicted than men, the highest incidence occurring in the fifth and sixth decades of life. Skinner estimates that routine gastrointestinal series show hiatal hernia in 10% of the population, with 5% of this group having pathologic reflux. If these figures are correct, significant gastroesophageal reflux disease is present in more than 1 million Americans. To be sure, one may take issue with the fact that the radiologic examinations were presumably requested for upper gastrointestinal symptoms and that the reported frequency, therefore, is unnaturally high. Identification of the stomach above the hiatus,

moreover, depends both on the technique used by the radiologist and the sensitivity of his or her interpretation. When maneuvers such as abdominal compression are used, the incidence of hiatal hernia has been recorded in as many as 54.6% of patients.1 • Similarly, if encouraged and looked for, reflux has been found in more than 60% of another large group of patients, all ostensibly without symptoms.1 • As if to

confound the skeptical clinician further, one of five patients with proven symptomatic reflux has no radiologically demonstrable hiatal hernia. This case exists when the esophagus joins the stomach like the neck of an inverted funnel. It is an important concept and merits some reflection ( Fig. 9-1 ). INCOMPETENCE OF THE LOWER ESOPHAGEAL SPHINCTER WITHOUT HIATAL HERNIA

Reference has already been made to Nissen's first fundoplication for reflux in a patient with reflux but no

Figure 9-1 The surgeon must understand the variably deranged physiology as well as the anatomic consequences of slack tethers and a wide hiatus.

Figure 9-1 The surgeon must understand the variably deranged physiology as well as the anatomic consequences of slack tethers and a wide hiatus.

Hiatus Hernia Figure

Figure 9-2 Pain patterns. The location of the discomfort from gastroesophageal reflux varies. Patients themselves shaded In the original sketches.

Figure 9-3 Transthoracic approach to paraesophageal hiatal hernia—first step. The esophagus is encircled and cleared to the Inferior pulmonary vein, after which the sac is opened close to the diaphragm.
Belsey Mark
Figure 9-4 Transthoracic approach—second step. An antireflux operation, in this case the Belsey Mark IV, Is performed.

Figure 9-5 Transthoracic repair completed. The transdural sutures are placed posteriorly. On occasion, anterior sutures may be required as well If the defect is huge.

Figure 9-6 Abdominal approach to paraesophageal hiatal hernia. Gentle reduction, closure of the hiatus (either anteriorly or posteriorly), an antireflux maneuver, and fixation of the stomach both at the hiatus and at the gastrostomy site are the essential operative components.

Figure 9-7 Long-term follow-up of operative patients. The population of entirely symptom-free patients declines even into the second decade. (From Hiebert, C.A., and O'Mara, C.S.: The Belsey operation for hiatal hernia: A 20-year experience. Am. J. Surg., 137:532, 1979, with permission.)
Paraesophageal Hernia Anatomy

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