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British Journal of Healthcare and Medical Research - Vol. 9, No. 4

Publication Date: August, 25, 2022

DOI:10.14738/jbemi.94.12720. Gharagozloo, F., & Ware, A. (2022). Historic Basis for the Modern Robotic Approach to the Anatomic and Physiologic Reconstruction

Hiatal Hernias. British Journal of Healthcare and Medical Research, 9(4). 96-122.

Services for Science and Education – United Kingdom

Historic Basis for the Modern Robotic Approach to the Anatomic

and Physiologic Reconstruction Hiatal Hernias

Farid Gharagozloo

Institute for Advanced Thoracic Surgery

University of Central Florida

Amendha Ware

Institute for Advanced Thoracic Surgery

University of Central Florida

ABSTRACT

A hiatal hernia is a common clinical entity which has been the subject of great

controversy for over a century. During this time, medical practitioners have been

like “blind” men who have examined the different parts of an elephant and reached

a conclusion based on the partial knowledge but have been unable to recognize the

“whole elephant”. The robotic approach to the repair of Hiatal Hernias which not

only incorporates the technology of robotics but is designed to return the anatomy

and physiology of the hiatus to its normal function, is the culmination of the work

of many surgical giants who independently identified specific parts of the

“elephant” that is represented by the entity of a Hiatal Hernia. The Robotic

Anatomic and Physiologic Repair of the Hiatal Hernia is also the result of a greater

understanding of the very complex normal and pathologic physiology of the

esophageal hiatus. Investigators from 5 specialties (cardiology, gastroenterology,

pulmonary medicine, surgery and radiology), using multiple modalities such as

echocardiography, computed tomography, exercise testing, respiratory function

testing, have shed new light into the pathophysiology and surgical indications for

the repair of Hiatal Hernias. An Understanding of the history of the surgical

treatment of Hiatal Hernias sheds light on the controversies and

misunderstandings that have characterized the surgical approach to this very

important condition.

Keywords: Hiatal Hernia, GERD, Paraesophageal hernia, Robotic Surgery, Laparoscopic

Repair, Nissen, Belsey, Gastroesophageal valvuloplasty

For the first half of the Twentieth Century, Hiatal Hernias (HHs) were repaired “Anatomically”.

Since the 1950’s until recently, Hiatal hernia surgery evolved from “Anatomic Repair” to

“Physiologic Restoration”. The anatomic repair of hiatal hernias was not successful in relieving

the symptoms in patients with hiatal hernias and reflux disease. Therefore, with greater

understanding of Gastroesophageal Reflux Disease, the pendulum moved toward purely

physiologic procedures, which to a large extent, ignored the complex anatomy of the esophageal

hiatus and its role in the natural antireflux mechanism. In fact, at one time in the 1970’s,

investigators proposed that hiatal hernias were irrelevant, and the answer was in the relief of

GERD. Today it is clear that in order to obtain the best results in symptomatic patients, both the

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Gharagozloo, F., & Ware, A. (2022). Historic Basis for the Modern Robotic Approach to the Anatomic and Physiologic Reconstruction Hiatal Hernias.

British Journal of Healthcare and Medical Research, 9(4). 96-122.

URL: http://dx.doi.org/10.14738/jbemi.94.12720

anatomic and physiologic aspects of the complex structure at the esophageal hiatus need to be

addressed.

The era which was characterized by the anatomic repair of hiatal hernias was hampered by a

lack of understanding of the actual anatomy of the hiatus and the gastroesophageal junction, as

well as the shortcomings of the open surgical techniques. It is now clear that the antireflux

mechanism is created by the complex anatomy at the esophageal hiatus. Therefore, restoring

the complex anatomy of the esophageal hiatus, also restores the antireflux mechanism.

In the past few years, a number of factors have been responsible for a slow but methodical shift

back to the correct anatomic repair. These factors have included:

1. Greater understanding of the complex three-dimensional anatomy of the esophageal

hiatus.

2. The relationship of the esophageal hiatus to the gastroesophageal antireflux mechanism.

3. The importance of the esophageal hiatus in providing the “skeletal” structure onto which

the gastroesophageal valve is suspended.

4. The non-gastrointestinal complications such as cardiac, respiratory and hematologic

complications that are associated with hiatal hernias.

5. Change in the definition of symptomatic hiatal hernias.

6. Possibility of complex anatomic reconstruction using minimally invasive techniques

which have been brought about from the advances in intraoperative three-dimensional

visualization and greater instrument dexterity provided by the robotic platform.

HISTORIC PERSPECTIVE

Anatomic Approach to the repair of Hiatal Hernias: an erroneous extrapolation from the

experience with Abdominal Wall Hernias:

Although congenital and posttraumatic diaphragmatic hernias were described as far back as

the 16th century by Ambrose Pare (1579), Rivierius Lazari (1689), Giovanni Batista Morgagni

(1761), and Vincent Alexander Bochdalek (1848), a Hiatal Hernia (HH) was not recognized as

a significant clinical entity until the first half of the 20th century.(1,2)

The first report of a Hiatal Hernia was by Henry Ingersoll Bowditch, who in 1853, in a review

of 88 cases with a diaphragmatic hernia which were reported between 1610 and 1846,

characterized the postmortem findings in 3 cases where “esophagus presented a very abrupt

change of its course. In all, it descended through the diaphragm as usual but turned back toward

the left to enter the abnormal aperture caused by the hernia and to join the stomach in the

chest.” (3)

The advent of radiography allowed for the antemortem visualization of the Hiatal Hernias. In

1900, Hirsch diagnosed a hiatal hernia by means of x-rays and a mercury-filled balloon prior to

autopsy. (1) Four years later, Eppinger diagnosed a Hiatal Hernia in a living patient. (4) In

1911, in a summary of the literature for diaphragmatic hernias, Eppinger identified 635 cases,

of which only 11 involved the esophageal hiatus. (5) In 1925, Julius Friedenwald and Maurice

Feldman described the symptom of heartburn and related it to the presence of a Hiatal Hernia

(HH).(6) They believed that the cause of the hernia was the failure of the muscle of the

diaphragm to closely encircle the esophagus. In 1926, Akerlund in Stockholm reported 30 more

cases of esophageal hiatal diaphragmatic defect, and for the first time proposed the term “hiatus

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British Journal of Healthcare and Medical Research (BJHMR) Vol 9, Issue 4, August - 2022

Services for Science and Education – United Kingdom

hernia” and classified hiatal hernias into 3 types. (7) Curiously this is the same classification

that is used today! He also noted that patients with HH complained of pain immediately after

ingestion of food, sometimes described “heartburn”, and sometimes complained of dysphagia.

He noted that “a diaphragmatic hernia through the esophageal hiatus may properly be termed

a Hiatus Hernia. They are most often true nontraumatic hernias and can be classified in 3

groups: a) hiatus hernias with congenitally shortened esophagus (thoracic stomach), b)

paraesophageal hernias, c) hernias not included in a and b.” In 1930, Max Ritvo, a Boston

radiologist, published a series of 60 cases with hiatal hernias.(8) Ritvo stated that the cause of

the “acquired esophageal orifice hernia” is the increased intraabdominal tension, which can be

caused by conditions such as constipation, pregnancy and obesity. He also reported epigastric

pain, heartburn, nausea, vomiting, and regurgitation as clinical correlates of hiatal hernia.

Despite these reports, the acceptance of Hiatal Hernia (HH) as a distinct entity was not

universal, with such giants as Kirklin and Sauerbruch considering the presence of Hiatal

Hernias on radiographic studies as an artifact. (9,10)

With the use of the term, “Hernia”, and the importance of inguinal hernia repair techniques in

the surgical practice of the early twentieth century, surgeons began treating esophageal hiatal

defects as they would “an abdominal wall hernia”. In 1919, Angelo Soresi reported the first

surgical approach to the repair of hiatal hernias which consisted of reduction of the hernia and

closure of the opening of the diaphragm. Interestingly he wrote: “patients suffering from this

condition are not properly treated.... This lack of interest is not easily explained, because

diaphragmatic hernias give rise to so many complicated and serious symptoms, which if not

properly attended to, will lead the patient to an unfortunate life and premature death”. (11) In

1928, Stuart Harrington published the the Mayo Clinic experience treating 27 patients using

the technique of the closure of the esophageal hiatus as described by Soresi. (12,13) Harrington

emphasized that: “closure of the hernia opening is essential for the relief of symptoms.” When

he was not able to close the diaphragm, he sutured the herniated viscera to the edges of the

hiatus (gastropexy), a procedure that he called “palliative.” He recognized that such a procedure

would not correct the problem, but it was the only possible action given the techniques of the

time. It is curious that many modern surgeons continue to perform “gastropexy”. He also

introduced “phrenic neurectomy” via a cervical incision as an adjunct in cases of large hiatal

hernias where the hiatus was difficult to close. The transection of the phrenic nerve was

designed to result in a flaccid hemidiaphragm and allow for a tension-free closure of the hiatus.

Unfortunately, the surgeons of this era did not appreciate the importance of freeing the

esophagus and complete dissection of the gastroesophageal junction. Using the rudimentary x- ray imagining modalities of the 1930’s, they reported the recurrence rate with this technique

to be 12.5%. Paralyzing the left hemidiaphragm was a technique which was rooted in the

treatment of inguinal hernias, where tension-free repair was obtained by various “relaxing”

procedures and was meant as a procedure to decrease the tension on the suture line. After two

decades, the technique of phrenic neurectomy was abandoned due to the unpredictable results,

complications from unilateral diaphragmatic paralysis, and the shift from anatomic repair to

functional repair of hiatal hernias in the 1950’s. Richard Sweet from Massachusetts General

Hospital first reported the application of this technique to a transthoracic versus

transabdominal repair of the esophageal hiatal hernias.(14,15) He too applied the principles

developed in the treatment of inguinal hernias, by reducing the hernia, crushing the phrenic

nerve, and plicating the hernia sac. He then narrowed the hiatus with heavy silk sutures until

he could get his index finger between the esophagus and the rim of the hiatus. Furthermore,