The surgical management of hiatal hernia presents a difficult problem, as indicated by the multitude of operations that have been and are still being devised for repair of this condition. Perhaps one reason is the conflicting opinion about physiological mechanisms involved in the prevention of gastroesophageal reflux. A second reason is the failure to understand that all patients with hiatal hernia do not have symptoms of reflux and may not require surgical repair.
Using manometric techniques, Code and coworkers outlined the motor function of a "physiological" sphincter intrinsic to the gastroesophageal junctional zone, and established certain criteria for the diagnosis of haital hernia.1,2 The addition of abdominal compression to esophageal motility studies allows assessment of the functional integrity of the sphincter during increased intra-abdominal pressure. Using this technique, Wankling et al3 found that whether or not reflux occurs in association with hiatal hernia depends on the ability of