• DOI:10.1007/s00464-007-9348-z
• Corpus ID: 9518509

Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how?

@article{Granderath2007MeasurementOT,
  title={Measurement of the esophageal hiatus by calculation of the hiatal surface area (HSA). Why, when and how?},
  author={Frank Alexander Granderath},
  journal={Surgical Endoscopy},
  year={2007},
  volume={21},
  pages={2224-2225}
}

• F. Granderath
• Published 4 May 2007
• Medicine
• Surgical Endoscopy

I read with great pleasure the ‘‘Letters to the editor’’ by Dr. Fourtanier and Dr. Reardon [1,2] regarding the problem of hiatal closure and particularly the definition and measurement of the hiatal defect. The growing discussion of this issue is distinguishing for its importance and relevance. The prevention of postoperative dysphagia caused by a too tight hiatal closure on the one hand as well as the prevention of a postoperative recurrent intrathoracic migration of the fundic wrap caused by inadequate crural closure on the other hand appears to be like being caught between a rock and a hard place. Undoubtedly, an exact and definite assessment of hiatal hernia size as well as a postoperative comparison of different hiatal closure techniques seems to be impossible as long as we perform the crural closure by our subjective estimation. Hence, I totally agree with Dr. Reardońs and Dr. Fourtanieŕs suggestion that there is a need for a standardized method for gauging the size of the hiatal defect and therefore allow an accurate comparison of crural closure techniques. As mentioned previously [2], the fundamental statement is that: [1] the closure of the hiatus is an important step of an antireflux procedure, [2] that calibration seems essential, and [3] particularly, it should be reproducible for all surgeons. A feasible device for hiatal calibration has been inaugurated by Dr. Fourtanier. With the HiaTech device (Laboratoire Surgical IOC Saint Etienne, France), a disposable instrument which is filled with 9ml serum and then passed through the hiatal orifice, a standardized method for hiatal closure seems to be available. This method appears to be a quick, simple and safe approach to a reproducible closure technique. However, the best way to get a maximum of information of the hiatal defect, and accordingly find the ideal diameter for closure of the hiatus, might be an exact definition of the real size of a hiatal hernia. In the same way as we do, Dr. Reardon recommends the measurement of the diameter of the hiatus by gauging the anteroposterior dimensions of the hiatus before closure, and consequently find an appropriate final diameter for adequate crural closure. In analogy to this method we have developed a method to define the size of the hiatal defect by calculating the so-called hiatal surface area (HSA), which should allow us to determine the two-dimensional expanse of the hiatal orifice and then adapt the crural closure to the exact dimension of the hiatal orifice. For measurement of the hiatal defect, an endoscopic ruler is brought intrabdominally. Firstly, the length of the crura is measured in centimetres beginning at the crural commisure up to the edge where the Pars flaccida begins (radius R). Then the circuit between the both crural edges are measured (s). With these two values, the angle of the crural commissure (a) is calculated using an inverse function (Figures 1 and 2):