Postgrad. med. J. (August 1968) 44, 579-585.

Hiatal hernia

JAMES S. DAVIDSONThe Royal Infirmary, Bradford

INGUINAL hernia, so beautifully illustrated andanimatedly discussed almost 200 years ago, stillhas a very definite recurrence rate after repair.In the repair of both inguinal and hiatal herniaroom has to be left for the passage of an anatom-ical structure, the spermatic cord and theoesophagus respectively, through a muscularopening without subjecting that structure tocompression. After repair of the hernia an open-ing remains which is a potential source of recur-rence. In hiatal hernia the problem is morecomplicated in that we are dealing not only withthe protrusion of an abdominal viscus but with avery delicate and only partially understoodvalvular mechanism at the oesophago-gastricjunction with a boiling cauldron of acid on oneside of it and a vulnerable mucosa on the other.Surgery is eminently successful in the relief ofobstructions whether they be in bowel, in thebiliary or urinary tract, or in a heart valve. Itis far less successful in the reconstruction ofone-way valvular mechanisms where co-ordinatedmuscle action plays such an important part. Imake this preliminary comment in order to ex-plain why any surgeon claiming 100% successin the treatment of hiatal hernia is a prevaric-ator and any physician expecting him to achievesuch success is an uncritical optimist.Having said this, I must hasten to add that, in

my opinion, the results of repair of uncomplic-ated hiatal hernia are good. The question immed-iately arises as to what criteria are to be used tojudge results. In the case of inguinal herniasuccess or failure may be decided merely byasking the patient to cough. In hiatal hernia, onehas to assess results on symptoms or post-operative radiological findings or both. Hereinlies a difficulty. It is well recognized that,although clinical success may be achieved in 80-90% of patients, the radiological cure-rate ismuch lower. Pearson & Gray (1967) reported83 % clinical successes as against radiologicalsuccess in only 40%. Raphael et al. (1965) saidthat 'although most reports indicate that themajority of patients experience symptomatic im-provement after operation, rates of recurrencebased on roentgenographic evidence vary fromB

1 to 48 %'. Although this discrepancy betweensymptomatic and radiological results is discon-certing, I think that, for practical purposes, it isthe patient's assessment of the operation whichis the important thing. In the case of an internalhernia, her heart does not grieve for what hereye does not see.The results of hiatal hernia repair depend to

a large extent on case selection. Rex et al. (1961)claimed that in a 10-year study of medicallytreated patients, 82% with minimal symptomsimproved on medical therapy alone. The verybest surgical results are to be obtained byoperating on patients who do not really requiresurgery. From what I have read in the literature,there is a tendency to describe the results ofsurgery in hiatal hernia while failing to detail thetypes of hernia operated on or to mention,almost as an aside, that complicated cases associa-ted with stricture have been excluded from theseries. I think that the results of surgery must besubdivided into those obtained in uncomplicatedhernias and those obtained in the presence of thevarious complications of hiatal hernia, especiallypeptic stricture, which adversely affect the rateof cure.The incidence of hiatal hernia in the general

population is unknown. All reported series haveundergone some selection. I have chosen a highlyselected group of patients, namely those I haveoperated on in the last 3 years. In spite of thedifficulties inherent in attempting to draw con-clusions from such a series, I have felt that youwould prefer opinions based on actual caserecords rather than vague impressions as seenthrough a surgeon's rose-coloured spectacles.The series consists of 117 patients. Of these,

eighty-one may be classified as uncomplicatedhernias. By this I mean reducible hernias eithersliding or para-oesophageal, the sliding herniasbeing usually associated with oesophagitis butwithout evidence of stricture at oesophagoscopy.Thirty-six patients are classified as complicated.

ComplicationsNo less than twenty-nine had peptic stricture

of the oesophagus. Two presented as strangulated

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hernia, two were associated with an oesophagealweb, two with a penetrating ulcer at the levelof the hiatus, and in one there was an achalasiaof the cardia in addition to the hiatal hernia.About peptic stricture I shall say more later

but at this stage I would like to say a wordabout some of the other complications.

(1) Of the strangulated hernias, one, a manof 58, came to hospital late and died of pre-renaluraemia. One patient who presented with painand vomiting was thought from the radiologicalappearances to have a strangulated hiatal hernia.There was indeed a hernia but the symptoms andX-ray appearances were produced by pyloricstenosis and eventration of the left dome of thediaphragm.

(2) The association of upper oesophageal webwith hiatal hernia was described by Smiley,McDowell & Costello (1963). Such webs are easyto miss radiologically and, without oesophagos-copy, the dysphagia may be attributed to thehernia. In one patient there were two oesophagealwebs, an upper and a lower. The upper one wassplit through the oesophagoscope and the lowerone was excised at thoracotomy. Incidentally,lower webs are easy to miss even at oesophagos-copy. They are extremely mobile and move downin front of the oesophagoscope. At thoracotomy,they may be difficult or impossible to feel. Onone occasion, when operating on a lower weband being unable to feel it, I had the anaesthetistpass a large stomach tube. The tube appearedto pass well down into the stomach and, at first,I thought the diagnosis was wrong. On closerinspection, it was found that the tube had pushedthe web down ahead of it. I have seen exactlythe same thing in a more recent case. I havenever seen this happen with a peptic stricture sothat I tend to support the view that, though suchwebs are usually associated with a hiatal hernia,they are not peptic strictures. The web is readilyremoved by submucosal dissection.

(3) In the patient with a hernia and achalasiaof the cardia, all the symptoms are relieved byHeller's operation and repair of the hernia(Fig. 1).The figure of thirty-six complicated hernias

does not include those associated with duodenalulcer, disease of the biliary tract, or diverticul-itis regarding which my figures are imprecise.However, I hope to have shown how frequentlycomplications exist which must inevitably affectthe results of surgery.

Indications for surgeryThe hig;h incidence of complicated cases in this

series may be a reflection of a certain restraint

which has been exercised in the selection ofpatients for surgery and this brings me to thequestion of case selection.

FIG. 1. Achalasia of the cardia associated with hiatalhernia.

(1) The most common indication for surgerywas the persistence of distressing heartburn andacid regurgitation in spite of medical treatment.Such treatment was based largely on alkalis andweight reduction. Getting patients in this groupto slim is difficult. One should be on the look-out for endocrine causes of obesity. I have hadoccasional patients with myxoedema whoseheartburn was best relieved by treatment withthyroxin. Conversely, symptoms may be initiatedor aggravated by weight gain under steroid ther-apy. Regarding posture, I think it is not alwaysrealized how high above the cardia is the fluidlevel in the stomach in the recumbent postureowing to the very different planes of theoesophagus and stomach (Fig. 2). Although prop-ping the patient up may reduce the fluid columnbelow the critical level of pressure necessary tocause reflux, the patient certainly has to bealmost bolt upright before the fluid level in the

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Hiatal hernia

stomach is at the level of the cardia. Occasion-ally, I think it is worth while trying to get thepatient to sleep face down (Fig. 3). An offenderin increasing reflux is the Goldthwaite belt forsore back. Sometimes the belt has become a

habit rather than a necessity and it may be dis-carded with benefit.

(2) Secondly, I have taken as an indicationfor surgery the persistence of heartburn with,in addition, dysphagia due to acute oesophagitis

FIG. 2. Lateral X-ray with the patient lying on her back showing the height of thebarium column in the stomach above the level of the cardia.

FIG. 3. Lateral X-ray with the patient lying face down showing the oesophaguslying above the barium in the stomach.

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James S. Davidson

as seen at oesophagoscopy but without strictureformation. There were twelve such patients.Rightly or wrongly, it was felt that operation insuch patients might prevent progressive changesin the deeper layers of the oesophageal wall lead-ing to peptic stricture.

This raises the problem of when repair of ahernia should be advised as a prophylactic mea-sure against peptic stricture. In practice, thepatient with a peptic stricture usually presentsas such. Only occasionally does one witness byserial X-rays the development of a stricture inan initially uncomplicated hernia. I think, how-ever, that acute oesophagitis together with dis-comfort on swallowing is an indication for sur-gery and also I think that a baby with a herniaor gastro-oesophageal reflux who regurgitatesblood-stained fluid should be operated on.

(3) Thirdly, strangulation is an obvious indica-tion for surgery. A history of episodes of painoften relieved by vomiting in the presence of alarge hernia is, I think, an indication to operatein order to avert strangulation. The most danger-ous type of hernia in this respect is the one whichcontains about half the stomach and in which apersistent fluid level is seen on the straight X-ray of chest, especially the lateral view. Paradox-ically, when all the stomach is in the chest, therisk of strangulation, though present, seems to beless, presumably due to the fact that the portionsof bowel entering and leaving the hiatus are lessbulky.

(4) Another lesion demanding surgery is thepeptic ulcer which goes on penetrating remorse-lessly and may involve the pericardium or theaorta. Such ulcers may be at or near the squamo-columnar mucosal junction, on the lesser curva-ture at the level of the hiatus, in the herniatedportion of stomach or in a gastric-lined oeso-phagus. In this series there were two patientswith an ulcer at hiatal level (Fig. 4). These ulcersoften bleed. They are of interest as I believethat the only treatment they require is repairof the hernia which moves the ulcer away fromthe margins of the hiatus (Davidson, 1958).

(5) A fifth indication for surgery is bleeding.Haematemesis may be a sufficient indication onits own. Anaemia presumed to be secondary toa hernia may respond quite well to treatmentwith iron but recurrent anaemia is often a factorinfluencing the decision to operate.

(6) Lastly, in this series, peptic stricture of theoesophagus was a frequent indication forsurgery.To recapitulate, the indications for surgery

were failure of medical treatment, acuteoesophagitis and dysphagia without actual stric-

ture formation, strangulation or a history ofepisodes of pain with a large hernia, penetrat-ing ulcer, haematemesis and sometimes recurrentanaemia, and peptic stricture of the oesophagus.

FIG. 4. A gastric ulcer at the level of the hiatus.

Peptic strictureThis is a large problem. As I have said, there

were twenty-nine strictures in this series. Thisfigure does not include all the peptic strictures Ihave seen in the past 3 years as, because of myapproach to the management of this lesion, anumber did not come to surgery. I am afraidthat I am in a somewhat bemused state concern-ing the correct treatment of this lesion. PerhapsI may illustrate my difficulties by describingsome types of stricture dealt with. Peptic stric-tures seem to me to fall into three groups fromthe clinical point of view.

(1) Firstly, there is the stricture which, atoesophagoscopy looks inflamed and oedematousand feels relatively soft and mobile. This is thetype of stricture which, theoretically, should res-pond well to control of reflux by repair of thehernia. In practice, the behaviour of such stric-tures is somewhat unpredictable. In this series,there are instances of at least three types ofresponse.

(a) Patients in whom successful repair of thehernia was achieved with disappearance of thestricture.

(b) Patients in whom the hernia recurred soonafter operation but in whom the dysphagia wasnevertheless relieved (Fig. 5).

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Hiatal hernia 583

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FIG. 5. Barium swallow showing recurrence of herniain a patient whose dysphagia was nevertheless relieved.

(c) Cases where neither successful repair ofthe hernia nor relief of the dysphagia wasachieved (Fig. 6).

(2) A second type is the high stricture with asegment of columnar-lined oesophagus abovethe hernia. There were at least seven suchpatients. They again respond in different waysto hernial repair. Some were cured. Others wereconverted from a long inflamed stricture tosmooth, rather web-like strictures which, incontra-distinction to their pre-operative state,were much more amenable to dilatation (Fig. 7).Some remained as tight as ever.

I am obviously unable to distinguish betweenstrictures which are going to respond to repairof the hernia and those which are not.

(3) Then there is a group of very hard stric-tures which neither respond well to dilatationnor disappear after attempted repair of thehernia. Three such strictures in this series devel-oped after an operation for duodenal ulcer. Thistype of stricture is, I think, a very definite entity.It is possibly related to the stricture which may

follow soon after delivery especially in hyperem-esis gravidarum as described by Abbey Smith &Nelson (1965). Dysphagia usually comes onabout 3 weeks after an operation, often an opera-tion for duodenal ulcer but also after a varietyof other procedures. A hiatal hernia has notnecessarily been present before the operation.My own view is that this stricture is due to anacute acid burn of the oesophagus during recum-bency under anaesthesia. Just as it is recommen-ded that alkali be given by mouth before anaes-thesia for labour in order to prevent Mendelson'ssyndrome, so, I think, we may come round tothe policy of giving alkali immediately beforeoperation on patients known to have a hiatalhernia or who have a peptic ulcer or hyper-chlorhydria. The following case record is typicalof this type of stricture:

Perforation of a chronic duodenal ulceroccurred in a man of 32. The perforation wasclosed. Three weeks later he developed dysphagiawhich became severe and led to emaciation anddehydration. The barium swallow showed thetapering column of barium characteristic of this

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FIG. 6. Barium swallow showing recurrence of herniawhere dysphagia persisted.

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stricture. The patient has done well for 2 yearson self-bouginage. It is of interest-that, althoughno hiatal hernia was seen at several previousX-rays over a period of some years, there isnow a hernia. It is debatable whether a herniaplayed a part in the occurrence of stricture orwhether it was, in fact, secondary to severechanges in the oesophageal wall produced byulceration and oesophagitis.

FIG. 7. Barium swallow showing a web-like stricture-persisting after repair of a hiatal hernia associated witha gastric-lined oesophagus. The stricture had previouslybeen long and inflamed.

Of the twenty-nine strictures, relief ofdysphagia by reduction of the hernia wasachieved in eighteen, improvement in five, andin six the stricture remained as tight as before.In view of these figures, I think that what has

been called a 'hopeful' repair of the hiatal herniaassociated with stricture is often justified espec-ially as there is a great difference in the severityof the operation between simple reduction ofthe hernia and excision of the stricture withcolon or jejunal replacement.My own attitude towards peptic stricture is as

follows but this is a strictly personal view. I tryto reduce the hernia if at all possible. There isno doubt that in a number of patients wherethe X-ray appearances and the findings atoesophagoscopy seen ominous, the hernia maybe easier to reduce than one might expect. Thisis particularly so when there is a high stricturewith a gastric-lined oesophagus when the actualstricture may be easy to reduce. I have notpractised Collis' operation to any extent. If thehernia seems quite irreducible or the patient isunfit or very old, I try to manage the case bydilatation before considering excision andreplacement with colon or jejunum. Dilatationvia the oesophagoscope gets rather a bad press. Iwould emphasize that, if repeated dilatation isgoing to succeed, there must be a close liaisonbetween the patient and the surgeon. It is nouse dilating the stricture and sending the patientaway to go through the laborious business ofseeking a further appointment through the usualchannels. The patient must be able to ring upand arrange for dilatation within a day or twoof recurrence of dysphagia. Also, with a co-oper-ative patient, I am sure that self-bouginage has avery definite place.Sometimes there is no alternative to excision

of the stricture but, in practice, I do few suchoperations for this lesion. It is indicated, I think,for a very hard stricture not responding to dilata-tion or where there is a penetrating ulcer whichis progressive. A peptic stricture in childhoodwhich does not respond to repair of the herniaand where the child fails to thrive and remainsseriously underweight is, I think, an indicationfor excision of the stricture and colon replace-ment.

Peptic stricture of the oesophagus may un-doubtedly undergo malignant change. Onepatient of mine had had a peptic stricture sincechildhood and developed a carcinoma at the siteof stenosis at the age of 42. How much oneshould be influenced in treatment by the poss-ibility of malignant change I do not know.

AnaemiaIn this series there were sixteen patients with

significant anaemia. Six of these had haemateme-sis. In one patient, although there was a hernia,the anaemia was due to bleeding from a

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Hiatal hernia 585

leiomyoma of the stomach. In two patients bleed-ing occurred from an ulcer at the level of thehiatus. In nine patients in whom the anaemiawas presumed to be related to the hernia, thehernia was invariably a fairly large one and itsrepair resulted in cure of the anaemia in seven.

ResultsIn the hernias I have classified as uncomplic-

ated 77 5% were asymptomatic after hernialrepair, 15% were improved, and 7-5 % wereno better. When there were complications, espec-ially stricture, only 61 % were asymptomatic, 25%were improved, and as many as 14% were nobetter.The main reasons for poor results were per-

sistence of reflux or recurrence of the hernia,and persistence of dysphagia. Results were poorin a group not always mentioned but which Iwould describe as instances of wrong diagnosisor ill-advised surgery. It is only too easy toblame symptoms on a blameless hernia. When,after operation, some patients, as in this series,express dissatisfaction because of buzzing in theears, nightmares, numbness round the ankles andblack dust in the water, one realizes that oneshould never have operated on them at all.

DiscussionI have purposely avoided discussion of surgical

technique. My own preference is for the trans-thoracic or thoraco-abdominal approach as I findit difficult to know how otherwise one can copewith the considerable number of patients withstricture and peri-oesophagitis. However, manybelieve otherwise and discussion of this matteris singularly unrewarding. I must admit that post-operative wound pain, which may on occasion,be severe and persistent, is a disadvantage of thethoracic approach. There is no time to describemy own not altogether successful efforts to solvethis particular problem.

I cannot understand those who would under-take the surgical treatment of hiatal hernia with-out routine oesophagoscopy. Even the best radio-logist cannot reveal all. At oesophagoscopy, onecan see the site of the oesophago-gastric junc-tion, get an idea of the function of the cardiaand certainly see the moderate and severedegrees of oesophagitis with superficial erosionsof the squamous mucosa. One can find a gastric-

lined oesophagus not apparent on X-ray. Onecan determine the level of the stricture and ifit is hard or soft, fixed or mobile. One can takea biopsy to exclude neoplasm. Inevitably one willdiscover from time to time associated lesions suchas webs which have been missed on X-ray.

In spite of all I have said concerning caseselection, I am sure that in many instances weknow not what we do. The oesophagus is a veryemotional organ. In no surgery that I practisedo psychological factors play such a big part.The fat woman of 55 who has, as they say, 'letherself go', who no longer feels needed by hergrown-up family and her disinterested husband,may seek comfort from the priest, the psychia-trist, the beautician, or the surgeon. Equally baffl-ing is the woman with the doting husband whodoes all the chores. We claim cure of heartburnby repair of a hernia when all we may havedone is to provide circumstances in which awoman who feels neglected may again becomean object of sympathy. We accept blame forfailures when the symptoms are in fact related tobusiness worries or domestic disharmony. Thedermatologist must be a psychologist and so mustthe oesophageal surgeon. It is very difficult toknow when an oesophagus is being digested byacid and when it is blushing for shame, piningfor love, quivering with anxiety, desolate withgrief, or merely reflecting downward trends onthe stockmarket.

I hope that I have succeeded in emphasizingthe complexity of the problem, at least as far asI am concerned, while at the same time showingthat the results of surgery in properly selectedpatients are good.

ReferencesABBEY SMITH, R. & NELSON, C.S. (1965) Oesophageal obstruc-

tion following hyperemesis gravidarum. Thorax, 20, 528.DAVIDSON, J.S. (1958) Gastric ulcer in association with

hiatal hernia. Lancet, i, 729.PEARSON, J.B. & GRAY, J.G. (1967) Oesophageal hiatus

hernia: long term results of the conventional thoracicoperation. Brit. J. Surg. 54, 530.

RAPHAEL, H.A., ELLIS, F.H., CARLSON, H.C. & ANDERSON,H.A. (1965) Surgical repair of sliding oesophageal hiatalhernia. Arch. Surg. (Chic.), 91, 228.

REX, J.C., ANDERSON, H.A., BARTHOLOMEW, L.G. & CAIN,J.C. (1961) Oesophageal hiatal hernia-a 10 year study ofmedically treated cases. J. Amer. med. Ass. 178, 271.

SMILEY, T.B., McDOWELL, R.F.C. & COSTELLO, W.T. (1963)Sideropenic dysphagia and hiatus hernia. Lancet, i;, 7.

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