Anatomy

Hiatal hernia is uncommon in children with gastroesophageal reflux disease. The operative findings almost always show normal gastric anatomy. Microgastria may occur in children with esophageal atresia.

Hiatal hernia is an uncommon finding in infants and children with pathologic gastroesophageal reflux. Most children and infants are found to have an intact hiatus and phrenoesophageal attachments. Additionally, it is rare for an infant or young child to have a foreshortened esophagus although this may occasionally be found in older children who have had untreated reflux for a prolonged period. Typically there is an adequate length of intraabdominal esophagus to allow creation of a fundoplication without circumferential mobilization of the esophagus.

As the fundoplication must be over the distal esophagus and not over the proximal stomach, identification of the gastroesophageal (GE) junction is critical. Several landmarks are useful in correct identification of the GE junction. First there is typically a small fat pad (Belsey’s fat pad) which sits over the GE junction. Second the angle of His is visualized after mobilization of the fundus. Finally the left gastric artery is caudal to the GE junction.

The vagus nerves must be protected during exposure of the GE junction. The posterior vagus is less adherent to the esophagus than the anterior nerve. The posterior vagus may be visualized during the retroesophageal dissection. This may be inadvertently dissected away from the esophagus during creation of the retroesophageal space. The anterior vagus is more closely adherent to the esophagus and gastroesophageal junction and may not be seen as a separate structure if extensive dissection of the phrenoesophageal attachments is not performed.

The short gastric vessels traverse the gastrosplenic ligament and are routinely divided during mobilization of the fundus. There are typically five to seven of these vessels which arise from the splenic vessels and join branches of the left gastric and left gastroepiploic vessels. Typically these are shortest most cephalad. The left gastric artery arises from the celiac and enters the stomach along the cephalad portion of the lesser curve of the stomach. It marks the inferior extent of dissection to create the retroesophageal window. It may also visualized from a retrogastric viewpoint as the attachments to the fundus are taken down and the greater curve of the stomach is retracted rightwards.

What are important anatomic variants that are relevant during fundoplication?

An accessory or replaced left hepatic artery arises from the celiac artery or its branches in 10 to 20% of patients. These aberrant vessels typically traverse the gastrohepatic ligament and are at risk as this ligament is divided to visualize the right crus. Typically these can be preserved with the fundoplication being created cephalad to the aberrant left hepatic vessel.

Patients with heterotaxy syndrome typically have a midline globular liver. This may confound retraction to provide exposure of the gastroesophageal junction. These patients may also have asplenia or polysplenia without a dominant spleen. The gastric anatomy is otherwise typically normal. In contrast, children with situs inversus demonstrate typical anatomy transposed across the sagittal plane. Situs inversus is otherwise not associated with abnormalities of the stomach, spleen or liver. Both of these diagnoses should be readily identified on preoperative imaging studies.

Microgastria may occur as an isolated congenital anomaly but more commonly occurs as consequence of esophageal atresia. In these children there may be insufficient gastric size to accommodate fundoplication especially with gastrostomy tube placement. This can be identified on preoperative upper gastrointestinal contrast study and therefore should not be discovered during fundoplication.