Anatomical Variations in Hiatal and Upper Gastric Areas and Their Relationship to Difficulties Experienced in Operations for Reflux Esophagitis

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Abstract
A number of patients were seen whose initial operations for reflux esophagitis or hiatal hernia or both have failed. During the course of reoperation, anatomic variation were shown to contribute to these failures. A formal anatomic study was therefore undertaken in 36 fresh cadavers without hiatal hernias or factors pertinent to operative maneuvers. Mobilization of the left lobe of the liver was difficult in 30% of normal specimens; the hiatal crura were very thin in nearly half of the specimens; a tethering ligament (the gastrolienal ligament) between the fundus and superior pole of the spleen was present in half of the specimens, but there was ample space (7-8 cm) above the highest short gastric artery; the angle of His was highly variable in normal subjects; the bare area of the stomach required deliberate exposure and division in more than half of the subjects to obtain a wrap without tension and the posterior gastric vessels were a hazard in such mobilization. Attention to these matters should enhance the safety and success of transabdominal operation for reflux esophagitis.