Comment on: Progression of hiatal hernias [1]

Thank you for this very excellent communication. Those of us who work extensively in this area have long recognised the phenomenon of the historically enlarging hiatus hernia, with little documented supporting evidence. It is nice some are now available. Many patients describe having a small hiatus hernia with typical reflux symptoms of heartburn and regurgitation which over many decades goes on to become entrapment symptoms (dysphagia, early satiety, post-prandial chest discomfort) as the hernia has become larger, often seen on serial barium meal over years.

It has been evident during surgical management of these patients that the diaphragmatic defect is most commonly anterior, the pericardium being visualised behind the larger anterior crural defect as soon as the sack is reduced. This is not the situation with the smaller hernia where the pericardium is not exposed on dissecting the hiatus. This has led me to develop the concept of failure of the central tendon of the diaphragm and movement of the left crural pillar laterally. During repair, the left hemi diaphragm is transposed towards the midline and flattens the dome of the left diaphragm and is part of a very useful technique of closure of the difficult hiatal defect [2]. There is a possible association with connective tissue deficiency [3, 4]

These findings are congruent with the concept of the enlarging hiatus over time, further evidence that the large mixed para-oesophageal hernia is a later stage of hiatal herniation.