Mark IV repair of hiatal hernia by the transthoracic approach.

Abstract

AbstractFollowing 10 years of clinical evaluation of various surgical techniques for control of gastroesophageal reflux, the Mark IV repair was developed and has now been used in over 2,000 patients. The operation is performed through a left posterolateral thoracotomy and entails extensive mobilization of the esophagus up to the aortic arch with preservation of the vagus nerves, and a 240 degree semi‐fundoplication between the stomach and esophagus. The lower esophagus and its sphincter are returned to the abdomen when possible, and the two halves of the right crus of the diaphragm are gently approximated to create a posterior buttress. When indicated, surgical treatment of associated upper abdominal disorders can be accomplished through the thoracic approach. A review of 892 patients who had undergone Mark IV repair during a 10‐year period showed that 84% had an excellent or good result with an 86% follow‐up rate. The over‐all recurrence rate was 11%, with indications that a significant number of failures were due to deviations from the standard Mark IV technique. Surgical treatment of recurrent hiatal hernia by the Mark IV technique is technically difficult. Of the 892 patients reviewed in 1972, the late results in 98 were classified as unsatisfactory. Of these, 45 required further surgical treatment which consisted of a second Mark IV repair, resection of the cardia and reconstruction, or gastric resection. The late results of reoperation were excellent or good in 75% of patients. Dilatable strictures may be treated by the Mark IV repair, but there is only a 50% chance of success. Undilatable strictures require resection followed by interposition of left colon or jejunum. Prevention of stricture by recognition and treatment of reflux esophagitis is the best management.