anatomy of the crura of the diaphragm and the surgery of hiatus hernia

Thorax (1954), 9, 175.

ANATOMY OF THE CRURA OF THE DIAPHRAGM ANDTHE SURGERY OF HIATUS HERNIA

BY

J. LEIGH COLLIS, T. D. KELLY, AND A. M. WILEYFrom the Queen Eiizabeth Hospital, Birmningham

(RECEIVED FOR PUBLICATION JULY 3, 1954)

PART 1: ANATOMYThe aim of this work was to improve operative

technique in the control of gastric reflux in hiatushernia by more exact anatomical knowledge. Duringdissections to establish the nerve supply of the crura(Collis, Satchwell, and Abrams, 1954) it becameobvious that there were points in the anatomy of thearea which had not been fully described and werenot generally appreciated. It seemed reasonable topresume that the anatomical arrangements weredesigned for a functional result and that deductionscould be made from this study about the mechanismof the oesophageal hiatus.

MATERIALIn preparing the previous paper on the nerve

supply of the diaphragm, 14 dissections were madeand to this number a further 50 specimens wereadded for this survey. To estimate percentagefrequency of various arrangements this new block of50 dissections was used because of the ease of thecalculations. For dissection wire frames were made,which consisted of two concentric rings of strongcopper wire braced by radial supports of the samematerial. The fresh specimens were attached to theseand fixed in formalin before dissection.

STANDARD ANATOMICAL PATTERNThe considerable number of major points of

difference between specimens resulted in only 46%0of cases presenting a standard pattern. This type isin general accord with the text-book descriptionwhich is so largely based on the short but thoroughpicture given by Low in 1907.

Figs. 1, 2, 3, 4, 5 and 6 show the anatomicalrelations in this group. There is a large right crus anda smaller left crus which takes no part in the forma-tion of the oesophageal hiatus.The fibres of the right crus arise from the main

tendon and in varying degree from the medianarcuate ligament. Some of these fibres may arisefrom this latter ligament to the left of the mid-line

(see Figs. 5 and 6), but in all cases they can readily beseparated from the left crural fibres.

There is no decussation of muscle fibres in front orbehind the oesophageal orifice, but varying degreesof muscle overlap are a constant feature. The fibreson the extreme left of the right crus, which oftenarise from the median arcuate ligament, pass upwardsbelow the other fibres and cross over to form theright margin of the hiatus. Conversely, fibres fromthe right side of the right crus pass upwards abovethe fibres already mentioned to reach the left side ofthe hiatus. This produces an effect of a double-breasted coat, more or less well marked from caseto case, as shown by comparison of Figs. 1 and 3.When the cross-over effect is well marked it isreferred to here as a case with good overlap.

In the standard type the median arcuate ligamentis always present, although in many cases it is poorlydeveloped (36%).

SHIFT TO THE LEFTThe fibres forming the right aspect of the oesopha-

geal orifice often arise to the left side of the mid-line.When this only represented a spread of the origin ofthe right crus across the median arcuate ligament,the specimen was still considered to be of standardtype. This group does represent a shift to the left ofminor degree and is spoken of as a stage 1 shift.It is shown in Figs. 5 and 6. Other cases are notuncommon (34%), in which a more marked " shiftto the left " is present, and, in these, fibres belongingto the left crus take part in the right side of theoesophageal orifice. This point is at direct variancewith the standard description.The shading off to the left with definite participa-

tion of the left crus in the right side of the oesopha-geal hiatus is termed a " stage-2 shift " and occurredin 32%. of cases. A marked example of this is shownin Fig. 7. The overlap below the hiatus presents theusual pattern, but all the fibres forming the lowermuscle band come from the left crus. They crossover in a scissor-like fashion, a similar band coming

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J. LEIGH COLLIS, T. D. KELLY, and A. M. WILEY

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FIG. 1.-Standard type of musculararrangements at the oesophagealhiatus seen from the inferior surface.The quality of muscle is good, with agood overlap of the fibres from theright across to the left. The fibres

II pass inferiorly to the similar band1

passing from the left to the right.s / ~~~~~~~~~~Agood median arcuate i3present.Y

The fibres of the left crus take no. 1tpart in the boundaries of the

oesophageal orifice.B)

r->

FIG. 2.-Standard type seen from above.Good musculature and strong cross-over fibres are seen.

ORIFICE 9F-VENt ( AVVA

E O3VYERLAPYPINI-RI CIR'i:

L,|T ( RulM EDDAN RME N.OESOP ;-

r r-

Fr.i1'

Fig. 2

176

ORIFICE ' 9-lENA CA VO)VER L.APR-INI(RT CRUFT C-RC

'T C R U'JSMMEDIAAN ,t''N E-N[NTEROPHP.

NN -FFP C,

!1i-( F

Fig. I

e.Er




ANATOMY OF THE CRURA OF THE DIAPHRAGM 177

i ,,. i,_dL '51ii'011 1j1__4____J

.. .A; w v A v~~~3i0.

6r~ - ; 2 - 5 :.!.l.. ;:::.. . : :i

FIG. 3.-A weak variety of the standardtype seen from below. The muscle isquitegtoou, OUL LUC% UVfZLIAV Vl SJIIUI-between the two parts of the rightcrus is poorly developed. No medianarcuate is present.

FiG. 4.-The same specimen as shown inFig. 3, but seen from above. Thepoor overlap of fibres is againdemonstrated together with theabsence of the median arcuateligament.

A. ORIFICE FOR INFERIORVENA CAVA

B. OVERLAPPING FIBRES OFRT. CRUS

C. RT. CRUSD. LT. CRUSE. MEDIAN ARCUATE LIGA-

MENT0. OESOPHAGEAL ORIFICE

Fig. 3


B. OVERLAPPING FIBRES OFRT. CRUS



Fig. 4





.1 LI ... ...-

.. 1 2 3 4 5.2......4- - -. _ J_ A_ :. .A........"I-.A..0,Oi.....

6 7 8 9 1 0 11 1;2 1...3. 4

......

*. 12 3 4 2 6 7 8 9 10 11 12 .13

4. 5

FIG. 5.-Under-surface of a diaphragmshowing a stage 1 shift to the left.A strong median arcuate ligament ispresent, and many fibres destinedfor the right of the oesophagealorifice arise from this ligament tothe left of the mid-line. The left crusis separate from these fibres andplays no part in forming the oeso-phageal orifice.

FIo. 6.-Upper surface of same specimenas in Fig. 5. A muscle sheet is seenpassing from the left crus to theregion of the orifice of the inferiorvena cava. (Low, type 2.)

A R FICE FO NFERIO1VENA CAVA

IA OVERLAPPIN(-: FIBREf 5RT CRUSRT CRLUJ

LU% LT. CRUFMEDIANAR AN CMENT

\ OESOPHWA(-."EA.NKF. ¢

A. ORIFIC'E FO0 F ;.VENA C-AVA

C', RT CRUiD LT CRUSF MEDIAN ARCR. .:A

MENT0 OESOPHAGEAi aRI F

LOWrvpC 7MPr S

Fig. 5

178

A'

Fig. 6




ANATOMY OF THE CRURA OF THE DIAPHRAGM

2 32 -12,51, 6__.__.__.._._.S.i......6s8 O 11 1 3 4 1 ;; ;.3 A"'-'. ,........13 I-:?.4 ';s.ti,....i\se>S18.6. ...1-s_X 2 i@Xt. Ss7s8 -9. 10 11 1.2 13 1 1

-a.c- wwy 2 _30 4 5 :

KS A\ l


B. OVERLAPPING FIBRESFROM LT CRUS



Fig. 7

FIG. 7.-Under-surface of a diaphragmshowing a stage 2 shift to the left ofmarked degree. The band of fibreson the right side of the oesophagusarises wholly from the left crus andcrosses underneath, in scissor fash-ion; a corresponding band from theright crus going to the left oftheoeso-ohageal orifice. The median arcuateligament is absent.

FIG. 8.-This is the same specimen asseen in Fig. 7 shown from above.The complete cross-over in scissor-like fashion is shown. No medianarcuate is present.


B. OVERLAPPING FIBRESFROM RT. CRUS



179

Fig. 8





.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..

., S8 9 10 11 12 1 3 1'

FIG. 9.-The under-surface of a dia-phragm is shown which demon-strates a stage 3 or complete shift tothe left. The left crus supplies allmuscle fibres taking part in the for-mation of the oesophageal orifice.Note the overlapping fibres pass inthe same direction as with a standardtype diaphragm. This would bereversed in a congenital trans-position.

FIG. 10.-The upper surface of thediaphragm in Fig. 9 is shown.Most of the fibres forming theoesophageal orifice come from theleft crus. There is one large flatband swinging across from the rightcrus which bears some resemblanceto the band of Low reversed.

0 R F ( ;{]> ER 1VENA CAVA-OVFRLAPPIN" LiSpFR AL

C: T C.RIbIT CRUK,r.T.CRU -MEDIAN A. - aMENTOFSOPHA(,EP :IIFi, H

-..I

I

7';

.A. ORIFICE FO!VENA CAVA

B OVERLAPPINIT'JSRT. CRUS

D. LT CRUSE MEDIAN ARC

ME NJTO OESOP:-AG A

Fig. I 0Fig. 9

180




FIG. 11.-The under-surface of a diaphragm withAW; overlap of the fibres of the right crus is shown.

X ~~~~~Anadditional band can be seen passing fromthe left crus to the region of the inferior vena

4~~~~~ ~ ~ ~~~ ~~~ cava. Low, type I.

t v

FIG. 12.-This is the same specimen as seen in Fig.11, but after the overlapping fibres of the right2 . .~ crus have been tured back. The muscle of Low- ~~ type I can be seen passing in the direction of theinferior vena cava. It can be seen passing into

the fibres of the right crus, as depicted in thefigure from the paper by Low, Fig. 13.

.~~~~ ~~~~~~~~~~Fg I 2

12 3 4 5 6 7 8 9 10 11 12 13 14 ~l

C.

A. ORIFICE FOR INFER IOR VENA CAVAC. PT. CRUS0. OESOPHAGEAL ORIFICE1. 1OVERLAPPING FIBRES OF PT. C RUS2. 2MUSCLE OF 'LOW. TYPE 1.5. LT.CRUS

Fig. II

'I~~~~~~2.91I-~~~~~~~~~~5 6 7 8C.

Fig. 12A. ORIFICE FOR INFERIOR VENA CAVAC. Rtr-CPUS0. OESOPHAGEAL ORIFICE1. OVERLAPPING FIBRES OF Rr.CRUS2. MUSCLE OF LOW TYPE 13. LT. CRUS





from the right crus and passing to the left of thehiatus.

In one case (2%) it was the left crus which took themajor part in forming the oesophageal hiatus. Thisis termed a " stage-3 shift" to the left. This casecannot be in the nature of a transposition. Hadthis been so, the whole pattern would have been amirror image of the standard with, among otherthings, the overlap reversed.

MUSCLE OF Low: TYPE 1

Low (1907) described a muscle band about 4 mm.broad extending from the medial aspect of the leftcrus. This small bundle crossed over in front of theaorta above the level of the coeliac axis and passedobliquely through the fibres of the right crus.Eventually he traced it to the region of the orificefor the inferior vena cava. He found this in four ofthe 25 cases he examined. It was not found in anyof the 50 dissections used for this classification, butit was present in one of the 14 previous dissections.It is shown in Figs. 11 and 12 and the originaldiagram of Low is reproduced in Fig. 13. It isreferred to as a Low muscle type 1, to distinguishit from a more frequent but rather different band.

MUSCLE OF Low: TYPE 2This was found in 34% of cases. It is only visible

from the upper surface of the diaphragm (Fig. 6)and passes from the left crus in the direction of theorifice of the inferior vena cava, as in the type 1muscle. It is wider and flatter than the musclenoted by Low and is usually 10-16 mm. wide. Allits fibres are on the upper surface of the diaphragmand none pass between the fibres of the right crus asLow described. It is to be noted that none of thefibres or either of these muscles take any direct partin the formation of the oesophageal hiatus.

TRANSVERSE INTERTENDINOUS MUSCLEThere is yet another distribution of muscle fibres

in this area which in no way conforms with any ofthe anatomy previously described. This muscleband is shown in Figs. 14 and 15. It lies on thesuperior surface of the diaphragm and passestransversely behind the oesophageal orifice. Eachend gains attachment to the central tendon. Apartfrom the specimen shown in Fig. 15, it occurred in8% of the 50 specially dissected diaphragms.

CONSOLIDATED FINDINGS FROM DISSECTIONS OF50 DIAPHRAGMS

Muscle

Shape . .

Overlap .

Origin of fibres

Median arcuate I

Low muscle

Transverse intert

Cruira in an adult male.FIG. 13.-This diagram is taken from the paper by Low and shows a

similar arrangement to the specimen illustrated in Figs. 11 and 12.A band from the left crus passes over to the region of the orificefor the inferior vena cava and passes through the substance of theright half of the right crus.

-Good.. 78%/..Medium 16°/

LPoor.. .. 6%Long.. 52%.... .. .. .. Medium .. 32°/

XShort .. 160

rGood.. 86°/........qIMedium 10/LPoor .. .. 4',CAll right crus 66%/.... .. .. .. q Some left .. 32°/

tMainly left .. 2%rGood.... .54°/

ligament.Medium 10%/

LPoor 36%

~Nit. 64%oType I .. nil.... .. .. .. < (one in small series)

Type 2 .. 34%Reversed 2%/

tendinous muscle 8%

COMMENT ON CONSOLIDATED FINDINGSReference is made to the quality and length of the

muscle, and this will be considered further in thesection dealing with the deductions from theseobservations.One case which is shown in Fig. 10 is classed as

having a reversed muscle of Low. This is notabsolutely accurate, as the fibres in this musclewhich arise from the right crus take part in theformation of the oesophageal orifice. This specimenhas no exact place in the classification presented, butis included here for completeness.

182




ANATOMIY OF THE CRURA OF THE DIAPHRAGM18

23;4567 8~ 9%0

FIG. 14.-This is the under-surface of thesame specimen shown in Figs. I11and 12. The muscle of Low hasnow been turned back and a furtherset of transverse fibres can be seen.

Fio. 15.-This shows the upper surfaceof the same specimen as seen inFig. 14. The transverse band ofmuscle fibres marked P can be seenpassing horizontally across from onecentral tendon to the other. This isreferred to asa she transverse inter-tendinous muscle.

ORIFICE FOR INFE-RIORVENA CAVART. CRUSQESOPHAGEAL ORIFICETRANSVERSE INTERTEN-DINOUS MUSCLEOVERLAPPING FIBRES OFRT. CRUSMUSCLE OF LOW. TYPELT. CRUS

1 2 3 456678S.9 1.0 1.1

A. ORIFICE FOR INFERIOR

VENA CAVA

C. RT. CRUS

0. OESOPHAGEAL ORIFICE

P. TRANSVERSE INTERTEN-

DINOUS MUSCLE

3. LT. CRUS

Fig.14Fi.

A.

C.0.P.

I.

2.3.

183

Fig. I 5




J. LEIGH COLLIS, T. D. KELL Y, and A. M. WILEY

DEDUCTIONS FROM ANATOMICAL STUDIESIt seems clear from the study of these specimens

that the muscle around the oesophageal hiatus isdistributed in two ways. There are longitudinalbands stretching from the crura to the centraltendon and there are oblique and crossing musclebands. If it were not for the longitudinal masclefibres the descent of the rest of the diaphragm wouldtend to make wider the angle between the oesophagusand the fundus of the stomach. In view of the simul-taneous contraction of the longitudinal fibres thisangle is kept constant, because the point of theirinsertion into the central tendon descends to a paral-lel extent with the rest of the diaphragm. If, as isbelieved, this angle has an important bearing onpreventing regurgitation, its maintenance throughoutthe respiratory cycle is an essential factor.During the inspiratory phase regurgitation is more

likely because of the more pronounced negativeintrapleural pressure, and it would seem reasonablethat some additional mechanism should be availableto meet this need. It is suggested that the obliqueand overlapping arrangements are designed toprovide this force. The arrangements referred toinclude the double-breasted overlap, the varioustypes of shift of muscle fibres to the left, the muscleof Low in its two types and the transverse inter-tendinous muscle. Some sort of muscle distributionon one or more of these patterns is present in over95% of diaphragms, and it is suggested that thesefibres produce a scissor effect, tending to close offthe lower end of the oesophagus during the inspira-tory phase.The quality and the length of the muscle fibres

around the hiatus were also recorded as having abearing on the strength of the area. It would seemthat to some extent shortness of the muscle may becompensated for by more pronounced cross-overfibres, so that the whole area has a square appear-ance.

In one specimen a hiatus hernia was found. Thiswas unsuspected during life and no symptoms appearto have been produced by it. In view of this, it isinteresting to note that the muscle development wasgood and a well-marked type 2 band of Low waspresent. It is suggested that the explanation of theabsence of symptoms was due to the good musclewhich was producing valvular control of the stomachas it passed the powerful hiatus. The strength ofthe muscle may have been able to prevent grossregurgitation from the stomach below to the stomachabove the diaphragm, so that troublesome heartburndid not arise. Further arguments will be put forwardabout this at a later stage. These have reference tohiatus herniae in children which become asympto-

matic and also the operative production of stomach-to-stomach control with the object of controllingsymptoms. The finding of this hiatus hernia in aspecimen showing good muscle was at first sightrather upsetting to the general trend of thought onthe subject. However, if the explanation given aboveis correct, it would seem to strengthen and supportthe views expressed.Post-mortem material on patients suffering

symptoms from gastric reflux was not available, butthe opportunity was taken at 18 operations to observethe position. Uniformly in these cases the cruralmuscle would have been classed as medium or weakin strength, and in all but two cases the overlap waspoor.

SUMMARYThe findings from the dissection of 64 diaphragms

are described.The descriptions of Low are confirmed and with

considerable humility elaborated.The high proportion of cases in which the left

crus takes part in the hiatus is noted.The transverse intertendinous muscle is described.Certain conclusions about function are drawn

from these anatomical arrangements.

PART 2: SURGERY OF HIATUSHERN IA

As has already been stated, the object of theanatomical survey was to gain knowledge whichwould assist in improving surgical technique for thecontrol of gastric reflux and the repair of hiatushernia. Before actually considering the operationit would seem appropriate to view the picture on abroader basis than that of the muscular arrangementat the hiatus only.Although the term hiatus hernia is used in the

title of this paper, the major emphasis is laid onthe regurgitation of gastric contents. This is thecause of the main symptoms, and an operationcan only be considered as satisfactory if this isprevented or very materially reduced.

MECHANISM AT THE CARDIAThere are certain generally accepted ways in

which reflux from the stomach to the oesophagus isprevented. These may be listed under four headings.First, the obliquity of the insertion of the oesophagusinto the stomach; second, the sling fibres in thestomach; third, the muscle fibres of the right crus;and last, the weak sphincter of the lower end of theoesophagus.The position may be simplified still further by

considering that these various muscle masses are

184





____ WATER

FIG. 16.-This is a diagrammatic plan of the experimentsstrate the effect of increasing the angle between the oe!stomach. The copper tube over the angle could be lomThis wire was looped over a row of pins 4 cm. apart inseries of variations in the angle.

serving two functions. Either they are maintor increasing the angle of insertion of the oesopinto the stomach, or they are acting as a sphincthe lower end of the oesophagus. In the lattethe end is obtained by the weak internal sphin4the oesophageal wall and by the external sphproduced by the cross-over action of the righias already described.The longitudinal pull of the muscle fibres

right crus and the sling fibres of the stcproduce their effect by increasing the obliquityinsertion of the oesophagus into the stomac]this respect Barrett (1952) has demonstrate(the isolated stomach will not allow its conteregurgitate, provided that this incisura betwe4two organs is maintained. If, however, thephagus is pulled upon so as to obliterate this

fluid can readily be expelled from the stomachinto the oesophagus. This experiment wasrepeated and confirmed. Figures wererecorded for the pressure necessary to produceregurgitation with varying angles between theoesophagus and stomach. This angle wasvaried by lowering the copper tube with thewire as shown in Fig. 16. It was anticipatedthat the pressure necessary would be relateddirectly to the angle. The results obtainedshowed that free reflux occurred from the fullstomach without any increase of the intra-luminary pressure until a critical angle wasreached. At this point, lowering the copper

)NGE tube for half an inch produced an abruptrUBE change so that reflux became difficult or

impossible to produce. rhe adequacy of thevalve action remained constant from this pointand it would seem from this that the anglemechanism is a fully effective method of

WITH preventing regurgitation.rV /AN. The process of respiration makes this angleFCES difficult to maintain throughout the cycle.

The descent of the dome of the diaphragmtends to open the angle, but its effect is deli-

FOR cately balanced by a parallel contraction ofBOARD the right crus. It seems important to think of

this action of the right crus as maintaining theangle at all times, rather than to consider it asonly coming into action in inspiration. Unlessthis concept is appreciated it might be con-sidered that this angularity prevents regurgita-tion only in the inspiratory phase.From the anatomical studies it appears to

be the external sphincter produced by thedone to demon- cross-over arrangement of the fibres of thesophagus and the right crus which provides the extra force tovered by thewire.Pa board to give a prevent regurgitation in the inspiratory phase.

It is to be noted here that paralysis of the left:aining phrenic nerve will interfere with this mechanism and)hagus may actually aid regurgitation.;ter on It would seem reasonable to accept that refluxr case from the stomach is controlled by two mechanismscter in producing either a sphincter action on the lower endiincter of the oesophagus or a narrower angle between thet crus, oesophagus and the stomach. In the light of this,

all steps in the standard operation should beof the reviewed to ensure that these two ends are served.Dmachof theh. Ind thatnts toen theoeso-angle,

MOULDING THE OPERATIONMany surgeons have advocated interrupting the

left phrenic nerve. As has been shown by Collis,Satchwell, and Abrams (1954), this would have theeffect of paralysing the whole of the left half of thediaphragm, including the left half of the right crus.By raising the dome of the diaphragm the incisura

185-.





would be increased, but this advantage would beoff-set by weakness at the crus. These opposingfactors account for the variability in the results ofleft phrenic paralysis. A better plan would be toraise the dome of the diaphragm, while leaving thecrural fibres to function normally. It must also beremembered that, while the crural fibres pull on thediaphragm from the back, the anterior musclefibres balance this by contracting in front. Boththese actions are necessary for the effective functionof the crural muscles.

Selective elevation of the dome of the diaphragmwithout interfering with the crural action can beeffected if the lateral division of the phrenic nerve isdivided without cutting the anterior or posteriordivisions. This effect is produced by incising thediaphragm obliquely backwards and inwardstowards the hiatus as far as the anterior edge of thecentral tendon. This cut can be embodied into theoperation as part of the exposure of the area by anabdomino-thoracic approach, crossing the costalmargin at the eighth costal cartilage and opening upthe eighth intercostal space.

In dealing with the hiatus itself it is generalpractice to insert sutures so as to narrow the holethrough which the oesophagus passes. This generalnarrowing does prove effective in the same way as astricture protects the oesophagus above it. It is anunphysiological approach to the problem and has thedisadvantage that there is a group of cases mentionedlater in which it is quite ineffective. The successobtained by using this method does seem to provethat symptoms from acid regurgitation are producedby gross reflux and that a proportional improvementmay be expected from a proportional narrowing.It is suggested that the plastic repair of the hiatusshould be designed to increase the angle betweenthe oesophagus and the stomach. To effect this thepoint around which the oesophagus and stomachare angulated should be lowered. This can be doneby suturing the two parts of the right crus togetherabove and in front of the oesophagus, which in turnis displaced downwards and backwards. It is oftenpossible to increase this angle by as much as an inch.

This point is at direct variance with the Allison(1948) plan adopted by most thoracic surgeons, whoplace their stitches behind the oesophagus so as tonarrow the aperture, while pushing the oesophagusforwards and upwards. This movement of thepoint of angulation of the stomach on the oeso-phagus in an upward direction reduces the incisuraand must be a definite weakness in the method. Theplacing of the stitches in the suggested way fromabove downwards can only be done effectivelyafter dissection of the under-surface of the crural

area, and would seem to make it essential that thispart of the operation should be done from belowthe diaphragm; clearing this area allows downwarddisplacement of the oesophagus with consequentnarrowing of the incisura.

After this dissection of the crura and beforeapproximating the pillars of the right crus in frontof the oesophagus, one stitch can be placed behind.With this in place the stitches from above narrowthe opening and aid the external sphincter effect ofthe right crus. At the same time it is maintainedthat the lowering of the point of insertion of theoesophagus into the stomach, thereby narrowing theincisura, is the important step in the operation.

Before performing the plastic repair of the hiatus,the oesophagus and herniated part of the stomachmust be dissected in order to allow the cardia to beplaced in its normal position at the hiatus. In thispart of the mobilization it is sometimes an advantageto have access to the chest through the abdomino-thoracic approach. Dissection of the mediastinumabove the diaphragm may make this part of theoperation easier and may facilitate the difficultpoint in deciding whether a given part of the gut isoesophagus or stomach. As will be put forwardlater, over-emphasis should not be given to thepositioning of the cardia at the hiatus. Tensionon the oesophagus should not be allowed to reducethe effect of the plastic reconstruction of the hiatusso that the increase in the incisura is not obtained.It is felt that it is better to allow a small part of thestomach to be above the hiatus than for this tohappen. It is not considered that any attempt shouldbe made to elevate the diaphragm and stitch itaround the cardia in the chest. This is bound toproduce a funnel pointing upwards which willcompletely frustrate any plastic reconstruction of thenormal angle between the oesophagus and thestomach.

Finally, in closing, it is necessary to retain theoesophagus at the hiatus and at the same time fixthe fundus under the dome of the left diaphragm soas to maintain the incisura to the maximum extent.This can be effected by suturing the anterior surfaceof the fundus to the incision in the diaphragm whenthis structure is being closed.

In the overall plan for the operation it is alsonecessary to inspect the area adequately, and mayinclude examination of parts within the chest andalso laparotomy. This necessity is met by the useof an abdomino-thoracic incision.

OPERATIVE TECHNIQUEAfter induction of anaesthesia the patient has

sand bags placed under the left side so as to raise

186





this part about two inches from the table. The leftarm is placed at right angles from the side. Anincision is made from a point just above theumbilicus and across the costal margin and alongthe eighth intercostal space. It is carried backwardsto the edge of the latissimus dorsi. This muscle isfreed from the chest wall by blunt dissection so thatthe incision in the muscle layers can be carriedunderneath it. The serratus magnus is incised, andagain the muscle is lifted from the chest wall pos-teriorly beyond the edge of the latissimus dorsi.The area of interdigitation of the serratus andexternal oblique muscles is lifted from the chest walland the incision carried forwards through thelatter muscle and over the costal margin. Theanterior sheath of the rectus is cut and the rectusdivided across its fibres.The eighth intercostal space is then opened and a

section of the costal margin removed. This is animportant step, as it makes closing easier andprevents a painful area after operation. The abdo-men is opened immediately below the costal marginand the incision carried forwards through theposterior sheath of the rectus.The diaphragm is then incised to the anterior

edge of the central tendon but no further. Thisincision cuts all the divisions of the lateral branch ofthe left phrenic nerve.The peritoneum is incised above the hiatus and

the left pillar of the right crus is brought into view.To the right of the oesophagus the lesser omentummust be punctured and cut before the right pillar ofthe right crus can be dissected free from peritoneum.At this stage a laparotomy can be performed to

check for the presence of a peptic ulcer or gall-stones. Then a sling is put around the gut at thehiatus. This facilitates the mobilization and identifi-cation of the parts.With this done and the crural fibres cleared down

to the coeliac axis, the nature of the overlap of thefibres is noted and a stitch inserted as low down aspossible in this area. This stitch attaches togetherthe two limbs of the right crus in the area of theirdouble-breasted overlap.

Attention is now turned to the area above and infront of the oesophagus and the crural fibres aredrawn up in a tent fashion while the oesophagus isdepressed downwards. A series of sutures is nowput in this area between the two limbs of the crus.Care must be taken that these stitches are notinserted too deeply as otherwise the posterior branchof the phrenic nerves on each side may be damaged(Collis, Satchwell, and Abrams, 1954). The lowestof the stitches pulls the limbs of the right crus

tightly around the oesophagus and tends to hold itfirmly in position.The incision in the diaphragm is now closed with

interrupted thread, which is the same suture materialas has been employed in the plastic repair of thecrus. The first sutures are put in most posteriorlyand with the third and fourth suture the anteriorwall of the fundus of the stomach is included. Thismaintains the cardia in position at the hiatus andensures that the fundus is applied to the dome of thediaphragm. The chest and abdomen are then closedwithout drainage, but with care to see that the lungis fully expanded. No special post-operative careis required, and in about half the cases no aspirationof the chest is needed.

SCOPE OF THE OPERATIONThe operation is designed as a plastic repair to

prevent acid reflux from the stomach to the oeso-phagus. Its secondary purpose is to maintain thereduction of the hiatus hernia. It is suitable notonly for all types of para-oesophageal and slidingherniae, in which the oesophagus will reach thehiatus, but also for some patients with shortoesophagi. When employed in this group the plasticoperation produces a valve between the stomachbelow the diaphragm and the herniated part above.When using the operation for this purpose it isnecessary to be certain that the main symptoms aredue to regurgitation from the stomach below thediaphragm. There is a clear case for consideringthis to be so in patients who have a short oesophagusbut in whom no oesophagitis is present, but thesituation is not so clear when oesophagitis exists.

Aylwin (1953) believes that acid regurgitation inthe daytime produces heartburn, but is neutralizedso quickly by alkaline saliva that the pepsin cannotact on the oesophageal wall. During sleep, acid inthe oesophagus is not neutralized in the same way,and in consequence pepsin activity is possible.After a large series of tests he came to the conclu-sion that the increase of acid at night was onlyproduced by oxyntic cells within the stomach pouch.These cells are usually few, so that it is only the ratherunusual case where oesophagitis from pepsindigestion is possible. On the basis of Aylwin'swork, cases with short oesophagus can be dividedinto two clear groups according to whether or notoesophagitis is present. It can further be consideredthat when no oesophagitis is present the patient isnot suffering from the gastric pouch within the chest.The only exception to this rule would appear to bethose cases in which peptic ulceration affects thepouch. This is in the nature of an associateddisease rather than directly a result of hiatus hernia,

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and must be excluded before the division of patientsis made.

Tests of the same type as those employed byAylwin have been used in cases in this series, andgenerally his views have been supported. It has,however, been found that there are sufficient excep-tions to call for further investigation, which will bethe subject of a later communication. It does,however, seem reasonable to assume that all thecases without oesophagitis are only suffering fromreflux from the abdominal part of the stomach andthat more elaborate tests will be able to select somecases with oesophagitis who fall into the same group.

This theory was put into practice in three patientswith troublesome symptoms from gastric reflux,who had a short oesophagus without any evidentoesophagitis. The only alternative seemed anoperation of the type of oesophago-jejunostomywith Roux anastomosis as advised by Allison (1951).The patients were elderly and weak and such aprocedure was felt to be undesirable. By performingthe operation as described, but making no attemptto reduce the hiatus hernia, a valvular mechanismwas produced so that no reflux occurred betweenthe stomach in the abdomen and the herniated part.The object was achieved and symptoms relieved.

Belief in this as a practical procedure has beenstrengthened by the findings of Astley and Carre(1954), who suggest that a similar mechanismoperates in infants who spontaneously lose thesymptoms of hiatus hernia. Astley has been kindenough to demonstrate some series of radiographsin children passing through the phase of spontaneouscure, and there seems good reason to believe thatthev develop hiatal control. In this circumstancethe oesophagus remains short, but the control at thehiatus prevents gastric reflux from the major part ofthat organ below the diaphragm to the smaller partabove. Once control of gastric reflux has beenestablished they will be difficult to diagnose onbarium swallow examination. In these circumstancesthe nature of the condition can only be found atoesophagoscopy, and may tempt some people todiagnose the condition as a gastric-lined oesophagus.Patients with this arrangement are seen withsymptoms in later life, but in view of the frequencyof the condition in infants they must represent only asmall percentage of the people in whom thisabnormality exists. In view of these observations,the application of the operation to a group ofpatients with short oesophagus would seem to beonly a method of applying nature's own cure. Byexcluding cases with active oesophagitis trouble isunlikely to occur, while by testing the nightlysecretions of the oesophagus after operation a check

can be made that the pH is too low for pepsinactivity. This has been done in the three patientsmentioned.

FOLLOW-UPThe follow-up on this small group of 71 personal

cases must of necessity be of very limited value, andit is only included to emphasize a few points. It isgeneral experience that symptomatically a very highproportion of these patients are improved, but thedegree of improvement must be a matter open toindividual interpretation. As heartburn is the mainsymptom and is present occasionally in all normalpeople, it is difficult to see how an absolute assess-ment can be reached. Although many patients whostill have gastric reflux say that their symptoms arerelieved, it is felt that there is a direct relationshipbetween the amount of reflux and the improvementof symptoms. The major emphasis has been placedon the efficacy of the operation to control gastricreflux, and all patients have been given a standardtest. This consisted in laying the patient down inthe right lateral position after the stomach had beenfilled with barium. While the patient was in thisposition he was asked to cough and pressure wasapplied to his abdomen. The period under reviewwas from January, 1948, to January, 1954. Eachpatient was screened on discharge from hospital andat yearly intervals after this. In the case of theabdomino-thoracic approach, some follow-upperiods of as little as three months had to beincluded, as the operation by this method has onlybeen regularly used since March, 1953.

FOLLOW-UP DETAILS OF 71 PATIENTS WITH HIATUSHERNIA

-x

____rai°tm ___ 4_ _ _ _repair5 -~_ o-

LaparotomyrepamirO 35 3 23 7 1 1 7(23%/) 4(13%) 3 3Thoracotomyrepair 18 3 15 0 0 0 2(13,) 5(33',) 0 0Other pro-cedure 13 --

The cases under review fell into two groups.There were 35 patients in whom the operation hadbeen done through a laparotomy incision and 18in whom the abdomino-thoracic incision had beenused. It might have been appropriate to comparethe whole series with other cases treated by the

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thoracic approach, but the lack of tests of gastricreflux in recorded series made this impossible.The laparotomy series showed a high proportion

in which the hernia was unaffected (9 %) and afurther number in which some herniation remained(a further 9 %). It is felt that these gross defects havebeen allowed to occur because of the difficulty ofobtaining a good view of the operation area throughthis approach. The position has been corrected inthe series done through the abdomino-thoracicincision.With regard to the question of gastric reflux, both

series showed a high figure for cases having somepathological reflux. It was, however, found thatgross reflux had become less frequent in theabdomino-thoracic series and that this improvementhad run parallel to better symptomatic results. Inthe two cases with free reflux after operation throughthe combined approach it was found that the rightcrus had been paralysed. This was probably due tofaulty technique in the early cases done by thisroute. The incision in the diaphragm had beencarried well into the central tendon, and, althoughthis incision was planned to avoid the posteriordivision of the phrenic nerve, it is thought that thisnerve must either have been cut or over-stretched.The presence of this defect can be demonstrated byscreening the patient in the left anterior obliqueposition.

SUMMARYIt is suggested that the angle of insertion of the

oesophagus into the stomach is of great importancein controlling gastric reflux.The adjuvant effect of the crural muscle as an

external sphincter is also stressed.An operative technique especially designed to

promote these two actions is described.A case has been made for the use of this same

operation in one group of cases with short oeso-phagus.

We wish to acknowledge the help and facilities madeavailable by Professor J. W. Orr, of the Department ofPathology of the Birmingham University, and to Dr. W.Whitelaw and Dr. F. E. D. Griffiths, of Dudley RoadHospital, Birmingham. Our grateful thanks are due toMr. T. F. Dee, the clinical photographer to the QueenElizabeth Hospital, Birmingham, for the photographsreproduced here.

REFERENCESAllison, P. R. (1948). Thorax, 3, 20.- (1951). Surg. Gynec. Obstet., 92, 419.Astley, R., and Carre, I. J. (1954). Radiology, 62, 351.Aylwin, J. A. (1953). Thorax, 8, 38.Barrett, N. R. (1952). Proc. roy. Soc. Med., 45, 279.Collis, J. L., Satchwell, L. M., and Abrams, L. D. (1954).

Thorax, 9, 22.Harrington, S. W. (1945). Ann. Surg., 122, 546.- (1948). Surg. Gynec. Obstet., 86, 735.Low, A. (1907). J. Anat. Physiol., 42, 93.Sweet, R. H. (1948). New Engl. J. Med., 238, 649.

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Hiatus HerniaDiaphragm and the Surgery of Anatomy of the Crura of the

J. Leigh Collis, T. D. Kelly and A. M. Wiley

doi: 10.1136/thx.9.3.1751954 9: 175-189 Thorax

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anatomy of the crura of the diaphragm and the surgery of hiatus hernia

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