Anatomical variations in hiatal and upper gastric areas and their relationship to difficulties experienced in operations for reflux esophagitis.

We have seen a number of patients whose initial operations for reflux esophagitis or hiatal hernia or both have failed. During the course of reoperation, the authors have been impressed that anatomic variation contributed to these failures. Therefore, a formal anatomic study was undertaken in 36 fresh cadavers without hiatal hernias or factors pertinent to operative maneuvers. The data from this study suggest that 1) mobilization of the left lobe of the liver is difficult in 30% of normal specimens; 2) the hiatal crura are very thin in early half of the specimens; 3) a "tethering ligament" (the gastrolienal ligament) between fundus and superior pole of the spleen is present in half of the specimens, but there is ample space (7-8 cm) "above" the highest short gastric artery; 4) the angle of His is highly variable in normal subjects; 5) the bare area of the stomach requires deliberate exposure and division in more than half of the subjects to obtain a wrap without tension; 6) the posterior gastric vessels can be a hazard in such mobilization. Attention to these matters should enhance the safety and success of transabdominal operation for reflux esophagitis.