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International Medical Scientific Journal        Issue-3 

10.5281/zenodo.5701370 

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Art of Medicine           Volume-1 

International Medical Scientific Journal        Issue-3 

10.5281/zenodo.5701370 

64 

 

Art of Medicine International Medical Scientific journal 

 

Founder and Publisher Pascual Izquierdo-Egea 

Published science may 2021 year. Issued Quarterly. 

Internet address: http://artofmedicineimsj.us 

E-mail: info@artofmedicineimsj.us 

11931 Barlow Pl Philadelphia, PA 19116, USA +1 (929) 266-0862 

 

 
   

  



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Prosthetic hiatoplasty in surgical treatment of hiatal hernias 

Khashimov Sh.Kh., Sadikov N.S., Ligai R.E., Tsoi A.O., 

Tashkenbaev F.R., Zaripov A.A. 

Republican specialized scientific and practical medical center of surgery named 

after Academician V. Vakhidov. Tashkent, Uzbekistan 

 

Abstract. The article describes the experience of surgical treatment of hiatal 

hernias of types II and III. The authors proposed an original technique of prosthetic 

hiatoplasty aimed at the prevention of general and specific postoperative 

complications. The article presents an analysis of the immediate results of the 

proposed operation, as well as long-term results. 

Key words: hiatal hernia, prosthetic hiatoplasty, laser therapy, postoperative 

complications. 

Introduction 

In recent years, interest in the problem of hiatal hernias and gastroesophageal 

reflux disease has increased, since today they occupy a leading position in 

gastroenterology in frequency after gastric ulcer and duodenal ulcer and cholecystitis 

[2,3,9]. Hernias of the esophageal opening of the diaphragm account for 98% of all 

hernias of the diaphragm. It is important to note that in 50% of patients, it does not 

cause any clinical manifestations and, therefore, is not diagnosed [1,5,6,10,12]. 

The urgency and need to address the issues of effective treatment of HH is 

primarily due to the frequency of the spread of this disease - in 44% of the 

population, at least once a month symptoms of heartburn appear; 7% experience it 

daily; 18% are forced to resort to self-medication to eliminate the symptom [1,7,11]. 

Thus, approximately 1% of the population suffers from GERD symptoms, and 40% 

of the diagnostic examination reveals a hiatal hernia [8,11]. 

The need for further study of various aspects of this problem does not raise 

doubts, since the issues of choosing the optimal method of treatment have not been 

fully determined [5,9,12]. This has become especially important in recent years in 



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connection with the widespread introduction of endovideosurgical technologies in the 

treatment of HH [2,7,10]. 

Purpose of the study 

To study the results of a new method of surgical treatment of HH using 

prosthetic hiatoplasty. 

Materials and methods 

Department of Endovisual Surgery of the Republican specialized scientific and 

practical medical center of surgery named after Academician V. Vakhidov for the 

period from 2006 to 2019 has experience in the surgical treatment of 105 patients 

operated on for hernia of the esophageal opening of the diaphragm. 

When distributing patients, the comparison group consisted of 61 patients, 

where the choice of surgery was carried out based on the preferences and experience 

of the operating surgeon, some of which are currently not used due to frequent 

relapses of the disease. When choosing the operation, such indicators as the hiatal 

surface area (HSA) and the degree of atrophy of the legs of the diaphragm were not 

taken into account, and it is these indicators that determine the long-term results. 

The main group consisted of 44 patients, in whom a differentiated approach to 

the choice of surgical intervention depending on the HSA was used, as well as 

prosthetic hiatoplasty according to the original technique, both from the open and 

from the laparoscopic approach. 

After a comprehensive examination, including endoscopy, X-ray contrast 

study, and computed tomography, the distribution of patients by the type of HH was 

carried out according to the classification recommended in 2013 by the American 

Association of Gastroenterological and Endoscopic Surgeons (SAGES) for the 

treatment of HH [6], which includes 3 types of HH (Fig. 1). 



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Fig. 1. Types of hiatal hernia (SAGES, 2013) 

 

According to the classification, when examining patients, type II HH was 

diagnosed in 10 (9.5%), of which 7 (11.4%) patients in the comparison group and in 

3 (6.8%) patients in the main group. HH type III were diagnosed in 95 (90.4%) 

patients, of which 54 (88.5%) patients in the comparison group and 41 (93.1%) 

patients in the main group. The distribution of patients depending on the type of HH 

is presented in Table 1. 

Table 1 

Distribution of patients by types of hiatal hernia 

Size of hernia Comparison group Main group Total 

Type II 7(11,4%) 3(6,8%) 10(9,5%) 

Type III 54(88,5%) 41(93,1%) 95(90,4%) 

Total: 61(100%) 44(100%) 105(100%) 

Reliability χ
2
=0.64, p=0.42 

 

If with hernias of type II, the contents are the stomach, then with hernias of 

type III, in addition to the stomach, the hernial contents can be a loop of the small or 

large intestine, as well as a strand of the greater omentum. HH of type III was 

established in 95 (90.4%) patients, with subtotal gastric HH in 78 (74.2%) and total 

gastric HH in 17 (16.2%) patients. In this group, 15 (14.2%) of 105 patients had a 



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mixed nature of the HH content: small intestine - in 1 (1%), omental - in 6 (5.7%), 

colonic - in 5 (4.7%). %) and mixed (colonic + omental) - in 3 (2.8%) patients. 

The distribution of patients depending on the type of surgery is presented in 

Table 2. 

Table 2 

Types of surgical interventions 

Surgical intervention 
Comparison 

group 
Main group Total 

Allison's operation 4(6,5%) - 4(3,8%) 

Hill's operation 23(37,7%) - 23(22%) 

Collis's operation 1(1,6%) - 1(1%) 

Cruroraphy 33(54%) 18(41%) 51(48,5%) 

Cruroraphy with prosthetic 

hiatoplasty 
- 22(50%) 22(21%) 

Laparoscopic cruroraphy 

with prosthetic hiatoplasty 
- 4(9%) 4(3,8%) 

Total 61(100%) 44(100%) 105(100%) 

  

In the comparison group, the largest number was cruroraphy, performed in 33 

patients and amounted to 54%. Hill's operation was performed in 23 (37.7%) patients, 

Allison's operation in 4 (6.5%) patients and Collis's operation in 1 (1.6%) patient. All 

of the above operations, the execution technique of which is widely known and 

described in detail in the available literature, therefore we do not consider it 

necessary to dwell on their description in detail. 

As mentioned earlier, in the comparison group, the choice of surgical aid was 

based on the experience of the surgeon and his preferences. In the main group, the 

choice of surgical intervention was based on HSA and the presence of atrophy of the 

legs of the diaphragm. 

The technique for measuring the size of a hernial defect is not standardized, 

and the measurement of such an indicator as diameter is incorrect, since in most cases 

the HH has the shape of a triangle or, more precisely, an inverted drop. Granderath 

F.A. et al. in 2007 [4] was published article based on the intraoperative measurement 

of the indicator they proposed - HSA (Fig. 2). It is calculated using the equation: 



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HSA = arcsin (TD / 2 / VD) x VD
2 

VD - vertical dimension; TD - transverse dimension. 

  

Fig. 2. Measurement of hiatal surface area (HSA). 

 

Based on the method of measuring the indicator "hiatal surface area" 

Granderath F.A. et al. and the results of a retrospective analysis of 787 operations, 

created the classification of the HH: 

Small – HH <10 cm
2
; 

Large – HH 10-20 cm
2
; 

Giant – HH > 20 cm
2
. 

The applied value of this classification consists in a clear definition of the 

indications for the plastic technique (for small hernias, cruroraphy is indicated, for 

large and giant ones - alloplasty), which is evidence-based on the dependence of an 

increase in the frequency of relapses on the value of HH. 

According to the proposed indicators and classification, in the main group, 

when choosing a surgical aid, we analyzed the following parameters: F.A. 

Granderath, as well as the degree of atrophy of the legs of the diaphragm in large and 

giant hiatal hernia. 

HSA was measured intraoperatively according to the proposed equation. At the 

same time, in the main group, we obtained the following results: small HH was 

established in 18 (41%) patients, large in 17 (38.6%) patients and gigantic in 9 

(20.4%) patients. 

VD 

VD 

TD 



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In addition to HSA, the degree of atrophy of the pedicles of the diaphragm was 

assessed, which was also important in determining the indications in favor of 

prosthetic hiatus. The severity of atrophy of one or both legs of the diaphragm 

depended on the size of the hernial sac and the location of the latter relative to the 

median axis. Atrophy of the legs of the diaphragm is the result of compression by the 

hernial sac and ischimization in the pressure zone, followed by atrophy of one or both 

legs. The degree of atrophy of the pedicles of the diaphragm, as well as the HH, was 

assessed intraoperatively. When assessing this indicator, we obtained the following 

results: no changes were found in both diaphragm legs in 18 (41%) patients with 

small HH, atrophy of the left leg was detected in 18 (41%) patients, while the hernial 

sac was located to the right of the median axis. The right leg was, on the contrary, 

pronounced in 8 (18.1%) patients. 

After the analysis of the results obtained, in 18 (41%) patients, given the small 

size of the HH, the HSA is less than 10 cm
2
 and the absence of changes in the side of 

the diaphragm legs, there were no indications for prosthetic hiatoplasty. In 26 (59%) 

patients, in addition to the large size of HH, HSA was from 10 cm2 or more, and 

there was also atrophy of both one and both legs of the diaphragm. The totality of 

these indicators was an indication for performing prosthetic hiatoplasty. 

The original technique of prosthetic hiatoplasty used in the main group 

included two stages: operational and postoperative. We named it "A method of 

surgical treatment of hiatal hernia" for which a patent was received for the invention 

of IPA RUz IAP23124. 

Surgical stage: The method of surgical treatment of hiatal hernia includes, in 

addition to the conventional stages of surgery, selective proximal vagotomy, 

pyloroplasty according to Heinecke-Mikulich, the formation of a fundoplication cuff, 

behind the esophageal cruraphy, and the imposition of a U-shaped mesh implant on 

the suture area. At the same time, when the fundoplication cuff is formed, the anterior 

wall of the abdominal esophagus is captured, a U-shaped mesh prosthesis made of 

polytetrafluoroethylene (PTFE) is used, while the horizontal part of the prosthesis is 



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fixed to the diaphragm legs with interrupted (stapling) sutures, 3-4 mm away from 

the edges esophageal opening of the diaphragm, the free floors of the specified 

prosthesis are fixed to the diaphragm also with interrupted (stapling) sutures (Fig. 3). 

 

 

Fig.3. Cutting out the prosthesis and fixing it to the diaphragm. 

 

Postoperative stage. Starting from the first day after the operation, 5 sessions of 

percutaneous laser therapy are performed using the Sogdiana apparatus (Fig. 4). With 

mild pain syndrome, the pulse frequency was 80 Hz, with intense pain syndrome, 

1500 Hz, exposure time 256 s per 1 zone, daily during one session, 3 zones are 

affected - the lower third of the sternum, the epigastric region and the area of the pain 

point. 

 

 

Fig. 4. Laser machine "Sogdiana" 

 



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Research results 

When assessing the results, we assessed the frequency and nature of 

postoperative complications, the length of the patient's stay in the hospital, and also 

studied long-term results in terms of 1 month to 2 years. 

Postoperative complications. Complications that developed in the postoperative 

period were conditionally divided into general and specific. General complications 

developed in 20 patients, which amounted to 19%, and specific complications in 17 

patients, which amounted to 16.2%. All postoperative complications were eliminated 

by conservative measures and only in one case required relaparotomy. No lethal 

outcomes were observed. 

When analyzing the postoperative period, it was found that in 85 patients, 

which amounted to 81%, the latter proceeded without any postoperative 

complications. In 20 patients, which amounted to 19%, general postoperative 

complications were observed in the postoperative period (Table 3.) 

Table 3 

General postoperative complications. 

General complications. Comparison 

group 

Main 

group 

Total 

Without complications 43(70,5%) 42(95,4%) 85(81%) 

Postoperative complications 18(29,5%) 2(4,5%) 20(19%) 

Reliability χ
2
=10.33, p=0.0013 

Postoperative complications 

Suppuration of the wound 5(8,2%) - 5(4,7%) 

Bleeding from a wound 3(5%) - 3(2,8%) 

Pneumonia 2(3,2%) - 2(2%) 

Pleurisy 3(5%) 1(2,2%) 4(3,8%) 

Intra-abdominal bleeding 1(1,6%) - 1(1%) 

Cardiovascular complications 4(6,5%) 1(2,2%) 5(4,7%) 

Total 61(100%) 44(100%) 105(100%) 

 

In the main group, it was possible to reliably (χ
2
 = 10.33, p = 0.0013) reduce 

the number of postoperative complications from 29.5% to 4.5%. 



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The total number of specific complications observed in the immediate 

postoperative period was 83.8%. At the same time, thanks to a new method of 

surgical treatment of HH, in the main group it was possible to reduce the number of 

patients without specific complications from 73.7% in the comparison group to 

97.7% in the main group. Specific complications developed in 17 patients, which 

amounted to 16.2%. Analysis of specific complications is presented in Table 4. 

Table 4. 

Specific complications 

Specific complications Comparison 

group 

Main 

group 

Total 

Without specific complications 45(73,7%) 43(97,7%) 88(83,8%) 

Specific complications 16(26%) 1(2,2%) 17(16,2%) 

Reliability χ
2
=10.8, p=0.001 

Specific complications 

Dysphagia 7(11,4%) 1(2,2%) 8(7,6%) 

Reflux esophagitis 4(6,5%) - 4(3,8%) 

Gastrostasis 5(8,2%) - 5(8,5%) 

Total 61(100%) 44(100%) 105(100%) 

 

In the main group, thanks to the proposed method, it was possible to reliably 

(χ
2
 = 10.8, p = 0.001) reduce the number of specific complications from 26% in the 

comparison group to 2.2% in the main group. 

Among the specific complications in the immediate postoperative period, we 

noted the following: dysphagia was observed in 8 (7.6%) patients, of which in 7 

(11.4%) patients in the comparison group and in 1 (2.2%) patients in the main group; 

reflux esophagitis was observed in 4 (6.5%) patients, only in the comparison group; 

gastrostasis was diagnosed in 5 (8.2%) patients also only in the comparison group. 

The duration of the postoperative period. As the analysis of the duration of the 

postoperative period has shown, the number of patients with the shortest period of the 

postoperative period "up to 5 days" was observed in 4 (3.8%) patients. The largest 

number of patients were discharged within 5 to 7 days - 70 patients, which amounted 

to 66.6%. In terms of 7 to 10 days, 25 (23.8%) patients were discharged, and the 



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longest postoperative period of 10 or more days was observed in 6 (5.7%) patients 

(Table 5). 

Table 5 

Duration of the postoperative period 

Bed days Comparison group Main group Total 

Up to 5 - 4(9%) 4(3,8%) 

5-7 30(49,1%) 40(91%) 70(66,6%) 

7-10 25(41%) - 25(23,8%) 

10 and more 6(9,8%) - 6(5,7%) 

Total 61(100%) 44(100%) 105(100%) 

Reliability χ
2
=20,03, p=0.000008 

 

As follows from the table, thanks to the introduction of a new method of 

surgical treatment of HH, the stages of which are aimed at the prevention of 

postoperative complications, as well as the possibility of laparoscopic execution, in 

the main group, 91% of patients were discharged on the 5th day after the operation, 

and patients after laparoscopic operations were discharged on the 3rd and 4 days after 

surgery, which amounted to 9%. 

In the comparison group, there were no patients discharged within 5 days. With 

a favorable course, in the comparison group, patients were discharged within 5 to 7 

days and amounted to 49.1%. In terms of 7 to 10 days, 41% of patients were 

discharged with general or specific complications. The longest postoperative period 

was also observed only in the comparison group in 6 patients and amounted to 9.8%. 

Long-term results. After undergoing operations, out of 105 patients, in the 

long-term period from 1 month to 2 years, 93 patients were examined, which 

amounted to 88.5%, and 12 (11.4%) patients did not appear on time for the control 

examination. In the comparison group, out of 61 operated patients, 49 (80.3%) were 

examined, and 12 (19.6%) were not examined. In the main group, at various times 

after the operation, all 44 (100%) patients were examined (Table 6). 

Table 6 

Long-term observation 



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Terms of observation CG 

N=61 

MG 

N=44 

Total 

N=105 

Not observed 12(19,6%) - 12(11,4%) 

1 to 3 months 28(46%) 27(61,3%) 55(52,3%) 

4 to 6 months 17(27,8%) 11(25%) 28(26,6%) 

1 year 4(6,5%) 4(9%) 8(7,6%) 

2 years - 2(4,5%) 2(2%) 

Total 49(80,3%) 44(100%) 93(88,5%) 
 

In terms of 1 to 3 months, 55 (52.3%) patients underwent control examination, 

of which 28 (46%) were patients in the comparison group and 27 (61.3%) were 

patients in the main group. In the period from 4 to 6 months after the operation, 28 

(26.6%) patients, 17 (27.8%) patients in the comparison group and 11 (25%) patients 

in the main group were examined. A year after the operation, 8 (7.6%) patients, 4 

(6.5%) patients from the comparison group and 4 (9%) patients from the main group 

were examined. The longest follow-up period was 2 years after the surgery. During 

this period, 2 (4.5%) patients of the main group were examined.  

After examining 93 patients, we found that 77 patients had no specific 

complications, which amounted to 82.8%. In 16 patients, which amounted to 17.2%, 

various specific complications were revealed. Analysis of specific complications in 

the long-term period is presented in Table 7. 

Table 7 

Long-term specific complications 

Complications 
Comparison 

group 

Main 

group 
Total 

Without specific complications 37(75,5%) 40(91%) 77(82,8%) 

Specific complications 12(24,4%) 4(9%) 16(17,2%) 

Reliability χ
2
=3,86, p=0.049 

Specific complications 

Dysphagia 4(8,1%) 2(4,5%) 6(6,4%) 

Recurrent reflux esophagitis 3(6,1%) 1(2,2%) 4(4,3%) 

Gastrostasis 2(4%) 1(2,2%) 3(3,2%) 

Recurrent HH (clinically significant) 2(4%) - 2(2,1%) 

Recurrent HH (clinically insignificant) 1(2%) - 1(1%) 

Total: 49(100%) 44(100%) 93(100%) 

 



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In the main group in the long-term period, the number of specific 

complications was significantly (χ
2
 = 3.86, p = 0.049) lower than in the comparison 

group. 

Discussion of research results 

As follows from the table, dysphagia was established in 6 (6.4%) patients, 

while in 4 (8.1%) patients in the comparison group and in 2 (4.5%) patients in the 

main group. Recurrent reflux esophagitis was established in 4 (4.3%) patients, of 

which 3 (6.1%) patients in the comparison group and 1 (2.2%) patients in the main 

group. Gastrostasis was observed in 3 patients, which amounted to 3.2%. Of these, in 

the comparison group in 2 (4%) patients and in 1 (2.2%) in the main group. Relapse 

of HH was observed only in the comparison group in 3 (6.1%) patients. At the same 

time, a clinically significant relapse, accompanied by a relapse of preoperative 

complaints of heartburn, belching and feeling of a "lump" behind the breastbone after 

a meal, was observed in 2 patients, which amounted to 4%. Clinically insignificant 

recurrence of HH, not accompanied by any complaints, was observed in 1 patient, 

which was 2%. 

  



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Conclusions 

Partial or total necrosis of the hernial contents, which occurs during 

infringement in type II and III HH, determines the absolute indications for surgical 

treatment in the diagnosis of the latter; 

Measurement of the APF and assessment of the severity of atrophy of the legs 

of the diaphragm, with HH of the II and III types, is considered mandatory when 

choosing a surgical aid; 

If the SFA is more than 10 cm², as well as in the presence of atrophy of one or 

both legs of the diaphragm, prosthetic hiatus is indicated; 

The stages of the proposed method of surgical treatment of hiatal hernia are 

aimed at preventing the development of both general and specific complications in 

the immediate postoperative and long-term periods. 

The use of prosthetic hiatoplasty made it possible to reliably (χ
2 

= 10.33, p = 

0.0013) reduce the number of general postoperative complications from 29.5% to 

4.5%. Thanks to the proposed method, it was also possible to reliably (χ
2
 = 10.8, p = 

0.001) reduce the number of specific complications from 26% in the comparison 

group to 2.2% in the main group. 

In the main group in the long-term period, the number of specific 

complications was significantly (χ
2
 = 3.86, p = 0.049) lower than in the comparison 

group.   

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