1. Regular anatomy of the stomach

The regular anatomy of the stomach is shown here: the angle of Hiss and the gastric fundus are in their physiological positions.

1. Oesophagus
2. Aorta
3. Posterior vagus nerve
4. Anterior vagus nerve
5. Lower oesophagus muscle
6. Diaphragm
7. Angle of Hiss
8. Bicorn
9. Solar plexus
10. Liver branches
11. Branches to the pylorus
12. Stomach
13. Small intestine

2. Diaphragmatic hernia in situ

This shows what a diaphragmatic hernia in situ (in location) looks like in an affected person. It shows the angle between the oesophagus and stomach. In an untreated diaphragmatic hernia, this angle (angle of Hiss) is spread too far. The art of reconstruction is in reducing this angle to the regular size again and to fixate it anatomically correctly.

3. Repositioning of the stomach

As this figure shows, the stomach is returned to its natural position very gently with special stomach forceps. The relocation to its original position (reposition of the gastro-oesophageal transfer, the cardia, from the mediastinum to the abdomen) will stretch the oesophagus. This in turn increases the "pre-tension" in the oesophagus, so that the muscles can perform their pumping function more effectively again. In particular in case of a hiatus hernia, the oesophagus will "fold in" and thus shorten, and tension on the extension closure will be lost, which will cause it to (chronically) open, which has been proven to be a possible contribution to gastro-oesophageal reflux. 

4. Exposure of the hernia gap

This figure shows the hernia gap after it has been exposed. For this process, it is of the utmost importance to not injure any surrounding nerves and vessels. To the right of the stomach, the small network (omentum minus) is opened. This opening only takes place above the nerves and the vessels (Rami hepatici) leading to the liver. These are nerve ends of the N. Vagus and the additional left hepatic artery. The posterior vagus branch runs dorsally (behind) of the oesophagus. It radiates into the solar plexus. To safely protect the posterior vagus, it is not released from the oesophagus. The preparation takes place between the posterior vagus and the aorta. There is a layer that is nearly free of vessels there. Once it has been found, it can be cut easily. The anterior vagus also is not disconnected from the oesophagus. The preparation in front of the oesophagus also does not take place right at the oesophagus, but through the white lid fold. The anterior vagus branch or its ends remain attached to the oesophagus.

5. Closing the diaphragmatic hernia

The oesophagus with vagus branches is fastened with a suture. This way, the diaphragmatic hernia is completely presented and can be closed precisely. This reconstruction requires the ability to precisely guide the instruments via the surgery monitor to close the gap precisely and individually adapted to the specific patient. It is nearly always possible to close the gap with endogenous muscle-tendon tissue without using any foreign material. To prevent injury to the diaphragm muscle from the suturing material, the preparation is performed with special care to not injuring the peritoneum on the muscle. The peritoneum protects the diaphragm muscle when suturing. In case of small diaphragmatic hernias, closure of the hernia gap behind the oesophagus will be sufficient (dorsal hiatoplasty) to reduce the point at which the oesophagus passes through the diaphragm (hiatus oesophageus) to the regular size. However, always note that a diaphragmatic hernia in front of the oesophagus often is not very clearly visible.

6. Restoration of the angle of Hiss

There, the diaphragm edges, the diaphragm sides, are often too far apart. However, the peritoneum stretched over them will conceal the gap. In this case, a suture between the diaphragm sides in front of the oesophagus is required as well (anterior hiatoplasty). If the muscle edges are very thin or if the muscle is weak, it is sensible to reinforce the plastic closure of the diaphragmatic hernia, the hiatoplasty, with a partially absorbable net (Vypro II ® net, partially absorbable, composite polyglactin - polypropylene). This net is cut to size individually for the patient and placed around the diaphragm opening. It is fastened with non-absorbable sutures (Ethibond®). When fastening, it must be observed that the edge of the net reinforcement ends precisely a the edge of the diaphragm, to prevent irritation or mechanical damage to the oesophagus from the net. In 1994, Ablaßmaier used a net reinforcement for reconstruction for the first time. since these nets are individually adjusted and attached at a distance from the oesophagus, net complications have not been observed yet in the patients treated by Ablaßmaier according to this method.

7. Complete reconstruction

This figure shows the complete reconstruction. The upper bicorn-shaped share of the stomach is back in its original position. This forms a valve mechanism at the lower end of the oesophagus and prevents reflux of gastric content: the bottom part of the oesophagus is now back in the abdominal cavity. The more the bicorn-shaped part of the stomach is filled, the larger will the pressure on the oesophagus, which is adjacent on the right again, be. This biologically restores the natural valve function at the cardia.