FIGURE 1. Henry Ingersoll Bowditch reviewed the early series of hiatal hernias described at postmortem examination in 1846 and probably should be credited with the first description of what is now referred to as a paraesophageal hernia. (Courtesy of the National Library of Medicine.)

Philip Allison in Leeds and Norman Barrett in London played a major role in changing the established perception of the sliding hernia from that of an anatomic mechanical condition to a functional physiologically based disorder and established that reflux esophagitis and its complications were the physiologic consequences of anatomic abnormalities. Allison should be credited for initiating the modern era of antireflux surgery. In his classic paper published in 1951,31 he aimed to “emphasize the relation between the altered physiology at the cardia, and a common form of indigestion consisting mainly of heartburn, gastric flatulence and postural regurgitation” (Fig. 2A). He attributed the occurrence of these symptoms to reflux esophagitis due to incompetence of the gastroesophageal junction and he stated that “the cause of the incompetence is a sliding hernia of the stomach through the esophageal hiatus of the diaphragm into the posterior mediastinum.” Allison focused on the crural sling as the key factor in preventing reflux. He believed these crural fibers functioned as a pinchcock to prevent reflux. His transthoracic surgical technique consisted of (1) reduction of the herniated cardia back into the abdomen; (2) retention of the cardia to that position by suturing the phrenoesophageal ligament and peritoneum to the abdominal aspect of the diaphragm; and (3) approximation and light suture of the crural fibers behind the esophagus. Allison emphasized the importance of light suture so that the muscle fibers of the hiatus could continue to function. Allison classified hiatal hernia into 2 types: the sliding hernia and the paraesophageal or rolling, now more commonly designated as the type I and type II, and he observed that these 2 types give rise to different symptoms and had a different prognosis.

The development of the Nissen fundoplication has been falsely described as an example of progress in surgery by accident. In fact, Rudolf Nissen was a man of great power of observation, and his pioneering contribution was the result of 30 years of surgical trials (Fig. 3). Nissen, the son of a Prussian physician, began his career in Munich as an associate to Professor Sauerbruch. Although Nissen was to be remembered for the development of his antireflux operation, he began his career performing surgery for victims of tuberculosis. He was the first Western surgeon to perform a successful pneumonectomy, reporting this in 1931, 2 years before Evarts Graham did so in the United States.37 When Hitler enacted the Jewish Boycott in 1933, Nissen fled from Berlin and became chief of surgery in Istanbul. In 1936, he treated a 28-year-old man with a distal esophageal ulcer penetrating into the pericardium. The procedure performed was a transpleural mobilization and resection of the distal esophagus and cardia with insertion of the esophageal stump into the gastric fundus. In an effort to prevent leakage of the esophagogastric anastomosis, he implanted the distal segment of the esophagus into the anterior wall of the gastric body using the Witzel technique used for gastrostomies. The patient survived, and Nissen noted in follow-up that the patient's reflux symptoms had been abolished.38 In spite of this success, Nissen used the techniques of Harrington and Allison during the 1940s and early 1950s for treatment of hiatal hernias, but he was disappointed by the high incidence of relapses. In 1946, while chief of surgery at Maimonides Hospital in New York, the famous American radiologist Gustav Bucky came to see Nissen, desperately ill from an incarcerated paraesophageal hernia. Nissen reluctantly agreed to operate on Bucky but judged that Bucky was too frail to tolerate a thoracotomy. In spite of the fact that nearly all hiatal hernia repairs had been performed transthoracically, Nissen performed a laparotomy, reduced the hernia, and performed an anterior gastropexy. The patient recovered completely and remained free of symptoms throughout a follow-up of more than 15 years. At that time, Nissen felt that this procedure might prove effective in high-risk elderly patients, and he considered accentuation of the angle of His as the mechanism of action of gastropexy.39 It is unknown if Nissen was aware that Boerema had published the first description of anterior gastropexy (ie, the fixation of the lesser curvature of the stomach to the anterior abdominal wall) as the sole necessary procedure in the surgical repair of hiatus hernia 1 year previously.40 Though transabdominal hernia reduction and gastropexy remain useful adjuncts in the surgical management of paraesophageal hernias, the benefits of anterior gastropexy proved to be short lived for the management of sliding hernias and reflux symptoms. In 1955, disillusioned with the results of gastropexy, Nissen recalled the success of his procedure in Istanbul and opted to create a similar Witzel tube around the esophagus, though this time without esophageal resection. Furthermore, given the large experience with gastroplasty, he decided to perform this procedure transabdominally. Now in Basel, Switzerland, he operated upon a 49-year-old woman with a 3-year history of reflux esophagitis without a hiatal hernia. The phrenoesophageal ligament was divided and the esophagus mobilized, while the short gastric arteries were not divided. Using his right hand, he then passed the gastric fundus behind the stomach through an opening provided by the divided gastrohepatic ligament. A fundoplication was performed wrapping both anterior and posterior walls of the stomach around the lower 6 cm of the esophagus. He used 4 or 5 interrupted sutures, 1 or more of which also incorporated part of the anterior wall of the esophagus. The wrap was performed around a large-bore indwelling intraesophageal stent. The clinical outcome was excellent and was reproduced in a subsequent patient. These 2 cases were published in 1956, and Nissen named the operation gastroplication.41–43

Belsey followed his own principles rigorously, and perhaps the most salient lesson derived from his work is his remarkable restraint in deferring publication until the long-term success of his operation was assessed in a large number of patients. He called his final procedure Mark IV to serve notice that this was not his first thought (and possibly not his last) on the subject but the result of a series of surgical trials designated as Marks I, II and III. Mark I was essentially Allison's procedure, while Marks II and III represented various degrees of fundoplication. These initial 3 techniques were tested during the period 1949 to 1955, and the results were unsatisfactory in about a third of the patients. There were also 7 postoperative deaths. The final Mark IV operation was adopted in 1952; Belsey published his findings only after he became sufficiently satisfied with the durability of the technique he had developed. Thus, in 1961, Hiebert44 reported the results of 71 surgically treated patients with symptomatic reflux but no demonstrable hernia, and 6 years later in a classic and extremely influential paper, Skinner and Belsey45 reviewed the long-term follow-up of 1030 patients, most with hiatal hernia. With a minimum follow-up of 5 years, 85% of patients had no reflux symptoms (Fig. 4A).

In the 1970s, Nissen's fundoplication was rapidly adopted worldwide and became the most popular antireflux operation. The original operation underwent modifications by Nissen himself, as well as by other surgeons. Closure of the hiatus was recognized as an essential part of all antireflux procedures to avoid herniation of the fundoplication. An important modification was described by Rudolf Nissen's favorite pupil, Mario Rossetti (Fig. 5). 43 This was the creation of the fundoplication using only the anterior wall of the gastric fundus. As Hill was fond of pointing out, dysphagia was extremely common following a Nissen fundoplication. In Europe, construction of a partial wrap (less than 360 degrees) was proposed by Dor et al54 and Andre Toupet55 in an effort to minimize the postoperative symptoms plaguing patients who underwent Nissen fundoplication. When Toupet introduced this concept in the early 1960s, he was harshly criticized, and his procedure received little attention until the laparoscopic era. In the United States, Donahue et al56 and Demeester and Johnson57 also worked to improve on Nissen's operation. They were the first to truly understand the physiologic mechanism of Nissen's fundoplication and modified it by division of short gastric vessels and the creation of a loose floppy wrap. Demeester and Johnson evaluated the optimal length of the wrap and convincingly showed that a loose wrap of just 2 cm was sufficient for reflux suppression and reduced the incidence of troublesome postoperative bloating and dysphagia.58 It is this modification of the original Nissen fundoplication that is most commonly performed in the laparoscopic era.