Surgical Anatomy of the Esophageal Hiatus

Fig. 1.1

The clasp and sling muscle fibers that make up the lower esophageal reflux barrier in the contracted and relaxed state

Fig. 1.2

The anatomic relationship of the gastroesophageal junction, the phrenoesophageal ligament, and the diaphragm at the esophageal hiatus

Anatomy of the Diaphragm

The diaphragm has three major openings: the esophageal hiatus, caval hiatus, and the aortic hiatus (Fig. 1.3) The inferior vena cava (IVC) runs posterior to the liver and through the diaphragm at the right side of the central tendon. Although the IVC is generally not encountered during routine antireflux surgery it can be very close to the margin of the right crus during paraesophageal hernia repair (Fig. 1.4). There have been reports of surgeons mistaking the IVC for the right crus or even the esophagus, leading to disastrous complications. The diaphragmatic crura tether the diaphragm to the vertebral column. These “legs” of the diaphragm split from the central tendon and extend around the esophagus to create the hiatus. The area where the legs cross inferiorly to the esophagus and across the aorta is known as the crural decussation and median arcuate ligament. The right crus is typically straight at the hiatus while the left crus tends to bow out towards the left. This has implications when closing the crural defect in hiatal hernia repair as one often must travel farther on the left crus than the right for a symmetric closure.

Fig. 1.3

Anatomy of the inferior diaphragm showing the relationships between the esophageal, aortic and inferior vena caval hiatus as well as the central tendon and phrenic nerves

Fig. 1.4

The enlarged diaphragmatic hiatus following paraesophageal hernia reduction surgery. Note the location of the inferior vena cava in relation to the right crus

Exposing the Esophageal Hiatus

Most esophageal surgeries begin with gaining exposure to the esophageal hiatus. The gastrohepatic ligament (GHL) is divided to gain access to the right crus (Fig. 1.5). Typically, the anterior esophageal fat pad is retracted laterally to the left to maximize exposure and the GHL is divided leaving sizable accessory or replaced left hepatic arteries along with the hepatic branch of the vagus nerve intact. This maneuver will expose the right crus so that the PEL can be identified and divided to access the mediastinum and mobilize the GEJ. The left crus is more simply accessed by adjusting the fat pad retraction to the right and rotating the angled camera towards the left (Fig. 1.6). In cases of paraesophageal hernia (PEH), the hiatus is generally exposed and the PEL are elongated and loose (Fig. 1.7). In contrast to the division of the PEL in normal anatomy, this maneuver is actually much easier in a PEH surgery. A typical dissection begins at the 12 o’clock position at the hiatal margin far away from the esophagus (Fig. 1.8).

Fig. 1.5

Division of the gastrohepatic ligament provides access to the right crus. (a) Anatomy at the beginning of an esophageal surgery with normal anatomy. (b) Division of the gastrohepatic ligament, leaving the accessory left hepatic artery and hepatic branch of the vagus nerve intact, provides exposure to the right crus

Fig. 1.6

Identifying the left crus

Fig. 1.7

Typical anatomy in a paraesophageal hernia

Fig. 1.8

The PEL is divided at the 12 o’clock position and the dissection plane developed to reduce the hernia sac from the mediastinum. The PEL is then divided circumferentially as the hernia is reduced

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