Surgical Techniques Illustrated Spring 1976 [antikvár]

Indications The indications for operation in hiatal hernia are widening as the prevalence of the more disabling complications, such as esophagitis, aspiration pneumonitis, and certain secondary functional disorders of the esophagus, become more generally recognized — and as the long-term results of surgical treatment improve. The ability to achieve permanent relief in a high percentage of cases is itself an added indication, provided that the operative risks are minimal. The distressing complications of hiatal hernia can be averted by early diagnosis and prompt surgical control of the underlying gastroesophageal reflux. Too often, ineffectual medical treatment is continued till complications are firmly established and irreversible damage has occurred. Type of Operation Two divergent surgical philosophies prevail in the operative treatment of hiatal hernia: direct and indirect treatment. The direct treatment philosophy claims that if the symptoms and complications of hiatal hernia result from gastroesophageal reflux, then the logical aim of surgical treatment should be to control the reflux by restoring a competent valvular mechanism to the cardia. The indirect philosophy ignores the reflux but encourages attempts to minimize its sequelae by such procedures as vagotomy, pyloroplasty, and partial gastrectomy. Unfortunately, esophagitis may not only persist but may lead to the development of chronic peptic strictures of the esophagus in spite of numerous abdominal operations designed to take the "sting" out of gastric secretions and to reduce their erosive effect on the esophageal mucosa. The abdominal surgeon dedicated to the indirect philosophy should be encouraged always to attempt some form of repair in addition to the indirect procedures performed. Objective In the design of any operation for hiatal hernia, basic principles are of greater importance than technical details. Provided that the surgeon has a clear idea of what he is trying to accomplish, his manner of achieving it is less significant. Only in the Type II or "rolling" (paraesophageal) hernia is he reducing and repairing a true internal anatomical hernia. In the common Type I or "sliding" hernia, his aim is to restore a competent physiological valve to the esophagogastric junction. Lower Esophageal Sphincter This issue is devoted to surgical techniques designed to control gastroesophageal reflux. The wide variety of techniques currently practiced stems largely from a lack of precise information on the anatomical and physiological mechanism for the control of reflux in a normal person. There is growing clinical evidence, however, that restoration of the lower 3 to 5 cm of the esophagus, the area embracing the lower esophageal sphincter, to the high-pressure zone below the diaphragm plays a major role in achieving an efficient valvular mechanism. The role of the lower esophageal sphincter in controlling reflux is uncertain. That a sphincter exists can be demonstrated by motility studies and by the clinically observed tendency to recurring spasm of the sphincter in response to reflux. However, the sphincter is probably too weak and irresponsible to resist normal negative intrathoracic pressure when it is herniated into the thorax. Esophagoscopy under local anesthesia in the conscious patient, when normal intrathoracic pressure relationships exist, fails to reveal any sphincter mechanism at the esophagogastric junction. Returning the sphincter area to the positive-pressure zone below the diaphragm may restore its sense of responsibility and its ability to contribute to the normal control of reflux. Approach Discussion on the merits and demerits of the abdominal or thoracic approach frequently ends in an unseemly brawl that does no credit to the surgical profession. The protagonist of the abdominal approach claims greater ease of access to the gallbladder, bile ducts, stomach, and duodenum, the sites of additional disorders in 15% of cases of hiatal hernia; he also emphasizes the avoidance of postthoracotomy pain. On the other hand, the transthoracic approach through the sixth intercostal space, with extension of the incision across the costal margin and separation of the diaphragm anteriorly from its origin in the chest wall for a distance of 10 to 12 cm, affords excellent access to all these organs for any additional procedures that may prove necessary at the time of the hernia repair. Postthoracotomy discomfort can be minimized by attention to detail — a high thoracotomy, intercostal neurectomy, avoidance of wide and unnecessary rib distraction, and finally, refraining from overaggressive rib approximation during closure. The type of case referred to the surgeon may influence the choice of approach. In the absence of esophagitis, it is quite possible that a satisfactory repair can be achieved by the abdominal route. Once chronic esophagitis with secondary shortening or fibrous stenosis has supervened, any form of repair may prove impossible, and the surgeon may have no alternative but to proceed immediately with resection of the irreparably damaged segment of esophagus followed by some form of reconstruction. In this situation, which may be unpredictable, a left thoracic approach through the sixth intercostal space with division of the costal margin is preferable. The single most important step in restoring an interabdominal segment of esophagus is adequate mobilization of the esophagus up to the point near the aortic arch where the vagi pass from the lung hila to the esophagus. It is doubtful whether the necessary mobilization can be achieved from the abdomen.