SYMPTOMATIC HIATUS HERNIA

Herniations through the esophageal hiatus of the diaphragm often give rise to elusive symptoms that are common to many other abdominal disorders; they sometimes also lead to peptic esophagitis, severe hemorrhages, and strictures. The authors recommend that medical management be tried first but that operation be performed if such management fails to relieve symptoms. Of 65 patients who underwent surgery for symptomatic hiatus hernia, 45 had complained of pain that was poorly localized but commonly described as a sensation of fulness, bloating, or pressure. Esophagoscopy was carried out in 48 patients, and the findings were reported normal in 22. Surgical repair can be done by either the thoracic or the abdominal route. The essential aim is to bring the gastroesophageal junction back into position below the diaphragm and to keep it there. The hernial sac must be destroyed without injury to the sphincteral mechanism about the cardia. This depends upon a thorough understanding of the functions of the crura of the diaphragm, the muscularis mucosae and muscularis externa of the stomach, various parts of the endoabdominal fascia, and the left gastric artery in maintaining the usual position of the cardia. Close attention to detail is mandatory. The patients of this series were followed for periods of time from six months to seven years, and 59 of the 65 became and remained free from symptoms after operation.