Surgical anatomy of the diaphragm pillars:Technical considerations for the repair of hiatal esophageal hernia

Introduction. The pillars of the lumbar portion of the diaphragm make up the aortic and esophageal hiatus. The constitution of these pillars is still controversial as to its origin, disposition and relations. The aim of this study is to analyze the anatomy of the abutments, the configuration of the esophageal hiatus, as the basis for hiatal hernia repair. Material and methods. Prospective study designed on 10 cadavers dissected in the Chair of Anatomy of the Faculty of Medicine of the Catholic University at Murcia. Ten preparations of the entire diaphragm were carefully separated from their regional connections and maintained in formaldehyde. All dissections were recorded and the parts photographed and recorded for further evaluation. Results. The separation of the diaphragm is impossible without securing its fixations with the transverse abdominal muscle. The lumbar portion fuses with the aponeurosis of the transverse abdomen arid with the anterior sheath of the lumbodorsal fascia. The esophageal hiatus consists exclusively of fibers from the right abutment in 70% of cases. In the other 30% the left pillar participates through a small bundle of inconsistent fibers that reaches behind. Low's muscle appears in 20% of cases. Conclusion. 1) The diaphragm forms an anatomical unit with the transverse abdominal muscle. 2) The esophageal hiatus is usually formed by the decussation of the right abutment. The left pillar is rarely part of the hiatus. 3) The high variability in the anatomy of the abutments does not recommend suturing. 4) Repair of the esophageal hiatus and the diaphragm in general, should be carried out with the support of a mesh.