Research Article| Volume 2, ISSUE 1, P16-36, February 1997

The Hill Repair

Open Archive
The Hill repair for correction of hiatal hernia and surgical management of gastroesophageal reflux disease is defined as a cardia calibration plus posterior gastropexy. The repair includes restoration of the gastroesophageal junction (GEJ) with posterior anchoring and reconstruction of the gastroesophageal flap-valve mechanism (GEV). Intraoperative measurement of the lower esophageal sphincter pressure (LESP) is also performed on a routine basis. In laparoscopic cases we routinely perform intraoperative endoscopy to ensure adequate reconstruction of the GEV because of the inability to manually assess the valve.
In 1836, hiatal hernia was first clearly described by Bright
• Bright K
Account of a remarkable misplacement of the stomach.
in England. Bowditch in the United States was the first who suggested surgery as the treatment of choice for this condition. Surgical treatment developed slowly. In 1952, Ronald Belsey developed his transthoracic repair in England. In 1956, Rudolph Nissen described fundoplication. In 1963, the French surgeon André Toupet described a semifundoplication to be used in hiatus hernia repair and as a complement to Heller myotomy.
In 1967, Hill reported a procedure consisting of calibration of the lower esophageal sphincter and posterior fixation of the gastroesophageal junction to the median arcuate ligament. This procedure became known as the Hill repair. This original report presented an 8-year appraisal of 149 consecutive operations. As stated in that report the Hill repair is primarily aimed “at permanently fixing the gastroesophageal junction in its subdiaphragmatic location to prevent reflux and recurrent herniation.”
The ideal antireflux operation should accomplish the . following goals: closure of the esophageal hiatus loosely about the esophagus, reduction of the hiatal hernia with firm posterior fixation of the GEJ, calibration of the LESP to a normal range, restoration of the GEV, and prevention of a paraesophageal hernia. The Hill repair accomplishes these five goals.

Closure of the Diaphragm Esophageal Hiatus

To prevent a posterior sliding hernia the hiatus is closed loosely about the esophagus, allowing placement of one finger alongside the esophagus with a nasogastric (NG) tube in place. It is important to stress that a hiatus closed too tightly is a major cause of postoperative dysphagia. It is very difficult to endoscopically dilate the hiatus. In some rare cases of enlarged hiatus, additional anterior closure needs to be performed.

Reduction of the Hiatal Hernia With Firm Posterior Fixation of the GEJ

The secure fixation of the GEJ to its normal intra-abdominal location is a hallmark of the Hill repair and a key to the integrity of the antireflux barrier. This prevents recurrent herniation and is thought to improve length-tension relationships in the lower esophageal musculature, thereby improving abnormal motility in the distal esophagus in a number of patients. To accomplish this secure fixation, the preaortic fascia is used. This stout structure is the lowermost portion of both crura as they come together. It is anterior to the aorta and is anchored to the median arcuate ligament at the level of the celiac axis. Dissecting this ligament can be challenging for the inexperienced surgeon. Use of the ligament or preaortic fascia yields similar results.

Calibration of the LESP to a Normal Range

We have been performing intraoperative manometrics on a routine basis since 1978 and have shown that measuring LESP during surgery can help achieve better results. Objective evaluation of the sphincter pressure after the repair has been accomplished ensures that the quality of the repair will not be based exclusively on the “feeling” or observation of the anatomy by the surgeon. The repair is modified according to the reading of the manometer and anatomic appearance. The Hill repair allows adjustments in suture tension and thus in LESP during surgery. Patients with poor esophageal motility secondary to reflux are at a higher risk of postoperative sever dysphagia. In this group we use a lower intraoperative LESP. Intraoperative manometry is accomplished using a modified NG tube attached to a manometer. This tube has two portions: the standard sump part and an additional segment with an internal diameter of 1.2 mm, the tip closed and a built-in pressure-port constructed by cutting a 1-mm side hole 12 cm from the tip of the tube (Island Scientific, Bainbridge, WA). The manometer is a continuously perfused (0.7 mL/min) water system with a transducer and a digital reading.

Restoration of the GEV

The presence of the GEV and its role as an important component of the antireflux barrier has been under discussion for many years. Recently Grays Anatomy acknowledged the presence of this musculomucosal fold. We have found that grading of the GEV is simple, reproducible, and, in our experience, a better predictor of the presence or absence of reflux than measurement of LESP. We cannot assign relative importance to the LESP or GEV in preventing reflux, but we think that they both are components of the complex barrier to reflux; thus correction of the GEV should also be an aim of antireflux surgery.
In brief, we graded the valve as viewed through the retroflexed endoscope as follows:
Grade I. A musculomucosal fold that adheres closely to the scope trough all phases of respiration and is 3 to 4 cm in length (see Fig I).
Grade II. Slightly less well defined and shorter, opens occasionally but closes promptly and is competent.
Grade III. Opens frequently, is poorly defined, and is frequently accompanied by a hiatal hernia.
Grade IV. Stays open, no well defined fold is appreciated, and is always accompanied by a hiatal hernia.
Grade I and II valves are competent to reflux and grade III and IV valves are not.
During open surgery the recreated valve is palpated through the stomach, thus ensuring that a competent fold has been obtained after the repair. Because this option is not available in laparoscopic surgery we routinely perform endoscopy once the repair has been done but with the trochars still in place. If a grade I valve is not visualized or palpated, further stitches are placed.

Preoperative Workup

This includes history and physical with special emphasis to elucidate other causes of symptoms suggestive of gastroesophageal reflux disease. Achalasia, biliary disease, esophageal spasm, peptic ulcer disease, and cardiac ailments are some of the disorders that can clinically mimic gastroesophageal reflux disease.
Upper flexible endoscopy is essential to evaluate the valve, assess the grade of esophagitis, and obtain biopsy specimens (fundamental in Barrett's esophagus). Manometry is performed in nearly all cases; the information it provides concerning sphincter pressure and esophageal peristaltic function is very useful when suspicion exists that the symptoms are caused by achalasia or diffuse esophageal spasm. Even though we do not exclude from antireflux surgery patients with decreased esophageal body peristalsis when this is secondary to reflux (in contrast to patients with a primary motor disorder), manometry allows us to identify these patients and to perform a less snug repair aiming for a lower intra-operative LESP than in patients with normal peristalsis.
Upper gastrointestinal series is useful in cases of hiatal hernia and to evaluate stricture. If there is a question about the source of symptomatology, 24-hr pH monitoring confirms the diagnosis of reflux.
SURGICAL TECHNIQUE: OPEN HILL REPAIR
SURGICAL TECHNIQUE: LAPAROSCOPIC HILL REPAIR
Laparoscopic approach has been reserved to primary cases. Reoperative GEJ surgery is very demanding, and we think that in this setting an open repair should be attempted only when important experience has been obtained. Relative contraindications to laparoscopic approach include giant hiatal hernia, massive obesity, and previous upper abdominal surgery.
The low dorsal lithotomy position is used and endoscopy is performed once the patient is anesthetized to introduce a guidewire over which a dilator can be safely passed later when needed. The modified NG tube is also passed at this time.

Postoperative Care

Following an open Hill repair, the NG tube is attached to low intermittent suction until the residue obtained after 4 hours with the tube clamped is less than 200 mL. This usually takes 36 to 48 hours. It is important to ensure that the NG tube is patent at all times. Postoperative gastric dilation produces tension on the repair and can have disastrous effects. Once the NG tube has been removed, clear liquids are started (no carbonation) and, if tolerated, diet is progressed to full liquids or pureed foods. If the patient shows signs of gastric distention or vomits, liquids should be resumed. Gastric prokinetic agents can be useful in this setting.
In laparoscopic cases, the NG tube is removed once the procedure is completed, and clear liquids are started the night of the procedure or next morning. Patients are discharged on a soft diet and cautioned that some dysphagia to solids is not uncommon during the first few weeks after surgery. When indicated, postoperative endoscopy (Fig II) allows observation of the reconstructed GEJ.

Results

Our subjective rating of results after surgery is as follows: Excellent—no significant symptoms; Good—occasional heartburn requiring medication twice per week or less; Fair—significant heartburn, requiring; medication on a regular basis; Poor—unimproved or worse.
An ongoing multi-institution review has identified 2,253 open Hill operations: 1784 were initial operations for reflux disease and 469 were done as a subsequent repair to a previous antireflux surgery (of any kind). These 1784 cases divide as follows: 922 were done by us and have not been previously published, 492 were performed in four institutions by other surgeons, and 370 were done by us and have been previously published. We have analyzed 879 surgeries thus far (from the group of 922). We have found 92.15% good to excellent results, with an average follow-up of 109 months (range, 1 to 386 months).
From the group of 370 patients, 140 were available for follow-up at 15 to 20 years. These were added to 27 patients with the same follow-up and who had any kind of previous antireflux operation, thereby obtaining 167 total cases analyzed and published. At that moment, 88% of these patients evaluated their results as good to excellent. We also personally interviewed these patients applying strict subjective status rating criteria.
In brief: excellent—no recurrent symptoms; good—mild symptoms, no medication; fair—recurrent symptoms, adequate control with medication; poor—daily symptoms, unimproved, patients requiring reoperation.
Using these strict criteria, 78% were deemed to have good to excellent results. Considering that the mean follow-up was 17.8 years, we think that the Hill antireflux operation provides durable long-term results.
Laparoscopic application of the Hill repair was initiated in February 1992 after extensive animal experimentation. To date 338 laparoscopic cases have been performed. Our last retrospective review identified 307 patients with sufficient data for analysis. Subjective evaluation using the same evaluation criteria as for the open Hill repair showed 90.8% of patients with good to excellent results. Table 1 shows the percentage of patients with manometry or 24-hour pH monitoring. Average and median values of these objective evaluations after surgery indicate return to normal LESP and 24-hour pH monitoring (Table 2). Twenty-two patients had both preoperative and postoperative 24-hour pH monitoring. The preoperative median value was 11.2% of time with pH < 4 in the distal esophagus. After surgery this value became normal with a median of 2.1% of time pH < 4 in the distal esophagus.
TABLE 1Percentage of Patients With Objective Evaluations (n = 307) (Laparoscopic Cases)
PreoperativePostoperative
Manometry77.59%26.7%
24-hr pH25.08%19.8%
TABLE 2Objective Evaluations Before and After Surgery in 307 Laparoscopic Cases
PreoperativePostoperative
Average LESP (mm Hg) (Range)8.04 (0 to 50)18.68 (3 to 60)
Median value of % time 24-hr pH < 4 in the distal esophagus10.92.05

Conclusions

Of all the available antireflux procedures the Hill repair is the only one that securely anchors the GEJ to its normal intra-abdominal position. Recurrent hernia is thus rare and slipped repair nonexistent. This restoration of the normal anatomy also accounts for the application of the Hill repair in patients with diminished esophageal body motility secondary to reflux (not primary motility disorders) with good results and recuperation of motility to normal values in many cases. We recognize that patients with diminished motility are at higher risk for postoperative dysphagia but feel confident that the unique ability of the Hill repair to adjust suture tension during surgery allows to obtain a less tight (albeit competent) repair in these patients.
Unlike other groups that avoid surgery in these cases we do apply our technique in patients with abnormal motility secondary to reflux obtaining a rate of long-term dysphagia comparable to the group of patients with normal motility. (Short-term dysphagia is increased in patients with abnormal motility.) Objective feedback of the quality and snugness of the repair through intraoperative manometrics and endoscopic visualization of the GEV is another unique characteristic of the Hill repair and ensures reproducibility.
Another advantage of the Hill repair is that stitches do not enter the esophagus (in contrast with certain modifications of the Nissen) and complications such as long-term fistulas are not seen.
Finally the Hill repair is technically feasible laparoscopically, providing a safe and effective definitive antireflux repair. Our results are comparable to those obtained with the open technique with the obvious and well-known advantages of laparoscopic surgery over the traditional approach.

Acknowledgment

We wish to thank Wm. Dudson Bacon, MD, for his invaluable assistance.

Bibliography

• Bright K
Account of a remarkable misplacement of the stomach.
Guys Hosp Rep. 1836; 1: 598
• Bowditch HI
Treatise on Diaphragmatic Hernia. T. Jewett & Co, Buffalo, NY1853
• Hiebert CA
• Belsey R
Incompetency of the gastric cardia without radiologic evidence of hiatal hernia: diagnosis and management of 71 cases.
J Thorac Cardiovasc Surg. 1961; 42: 352-359
• Nissen R
Eine einfache operation zue Beeinflussung der Refluxoesophagitis.
Schweiz Med Wochenschr. 1956; 86: 590
• Toupet A
Technique d'oesophago-gastroplastie avee phr$eAnogastropexie apliqu$eAe dans la cure radicale des hernies hiatales et comme compl\$eAment de l'operation d'Heller dans les cardiospasmes.
Mem Acad Chir. 1963; 89: 394-399
• Allison PR
Reflux esophagitis, sliding hiatal hernia and the anatomy of repair.
Surg Gynecol Obstet. 1951; 92: 419-431
• Hill LD
• Kraemer SJM
• Aye RW
• et al.
Laparoscopic Hill repair.
Contemporary Surgery. 1994; 44
• Hill LD
An effective operation for hiatal hernia: an eight year appraisal.
Ann Surg. 1967; 166: 681-692
• Hill LD
• Kraemer SJM
Does modern technology belong in gastro-intestinal surgery? A step from subjective perception to objective information.
World J Surg. 1992; 16: 341-342
• Aye RW
• Hill LD
• Kraemer SJM
• et al.
Early results with the laparoscopic Hill repair.
Am J Surg. 1994; 167: 542-546
• Kraemer SJM
• Hill LD
• Low DE
The Hill-repair: Reconstruction of the gastroesophageal junction and the flap valve for gastroesophageal reflux.
in: Nyhus LM Baker R Mastery of Surgery. Little Brown, Boston, MA1992: 534-539
• Low DE
• Mercer CD
• James EC
• et al.
Post-Nissen-syndrome.
Surg Gynecol Obstet. 1988; 167: 1-5
• Thor KBA
• Hill LD
• Mercer DD
• et al.
Reappraisal of the flap valve mechanism in the gastroesophageal junction.
Acta Chir Scand. 1987; 153: 25-28
• Low DE
• Anderson RP
• Ilves R
• et al.
15 to 20 year results after the Hill antireflux operation.
J Thorac Cardiovasc Surg. 1989; 98: 444-450
• Hill LD
Intraoperative measurement of lower esophageal sphincter pressure.
J Thorac Cardiovasc Surg. 1978; 75: 378-381
• Hill LD
• Kozarek RA
• Kraemer SJM
• et al.
The gastroesophageal flap valve: in vitro and in vivo observations.
Gastrointest Endosc. 1996; 44: 541-547
• Russell COH
• Pope CE
• Gannan RM
• et al.
Does surgery correct esophageal motor dysfunction in gastroesophageal reflux?.
Ann Surg. 1981; 194: 290-296
• Hill LD
• Aye RW
• Ramel S
Antireflux surgery: a surgeon's look.
Gastroent Clin North Am. 1990; 19: 745-775
• Hill LD
The Hill procedure.
in: Zuidema GD Orringer MB Shackelford's Surgery of the Alimentary Tract. W.B. Saunders, Philadelphia, PA1996: 192-203
1. Alimentary system.
in: Bannister LH Berry MM Collins P Gray's Anatomy, the anatomical basis of medicine and surgery. Churchill Livingstone, Edinburgh1995: 1757
• Kraemer SJM
• Hill LD
Hill repair.
in: Pearson FG Deslauriers J Hiebert CA Esophageal Surgery. Churchill Livingstone, New York, NY1995: 319-329
• Hill LD
• Thor K
• Mercer CD
Surgery for hiatal hernia and esophagitis.
in: Hill LD Kozarek R McCallum R The Esophagus Medicaland Surgical Management. W.B. Saunders, Philadelphia, PA1988: 90-106