SUMMARY : The aim was to detect the presence of bundles of collagen fibers in the margins of the esophageal hiatus and establish if there is any relationship of these bundles with the anatomy of the hiatus. Ten adult male cadavers, with no gross anatomical alteration caused by trauma, surgery or disease, upon the esophageal hiatus were used in the study. With the aid of a digital caliper, measurements of the perimeter of the esophageal hiatus were done both in the abdominal and thoracic sides. For the structural study each margin was divided in six sections. Staining techniques of Masson and Picrosirius-hematoxilin were used. The right margin was statistically thicker than the left.
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SUMMARY : The aim was to detect the presence of bundles of collagen fibers in the margins of the esophageal hiatus and establish if there is any relationship of these bundles with the anatomy of the hiatus. Ten adult male cadavers, with no gross anatomical alteration caused by trauma, surgery or disease, upon the esophageal hiatus were used in the study.
With the aid of a digital caliper, measurements of the perimeter of the esophageal hiatus were done both in the abdominal and thoracic sides. For the structural study each margin was divided in six sections. Staining techniques of Masson and Picrosirius-hematoxilin were used. The right margin was statistically thicker than the left. These distances were smaller in cadavers who possessed bundles of collagen fibers in the margins of the esophageal hiatus.
The margins of the esophageal hiatus were predominantly formed by muscles fibers originated of the right pillar of the muscle diaphragm. The anatomical and morphometric data presented statistically significant values regarding: thickness of the right arm in relation to the left; distance between the vertex of the superior angle and the central tendon; and distance between the vertex of the inferior angle and the median arcuate ligament. The pillars of the muscle diaphragm have an essential role in anatomically delimiting the esophageal hiatus.
There are disagreements about various aspects of the anatomy of the hiatus, with consequent implications for surgery at this level, especially regarding variations in the participation of these pillars in forming the hiatus and in determining its type Costa, ; Cecconelo et al. Some authors believed that the margins of the esophageal hiatus would exclusively be formed by fiber bundles from the right pillar Moore; Low; Cunningham, ; Allison, ; Harrington, ; Madden, ; Botha, ; Marchand, ; Mann et al.
In the type A esophageal hiatus, the two margins emerge from the right pillar, while in type B the left margin emerges from the right pillar, and the right margin emerges from both pillars of the diaphragm. In this type, both two sides would arise from the right pillar, with lesser participation by the left pillar. Botros et al. Pataro et al. Some authors have accepted that the values of the craniocaudal and transverse diameters are important in the morphology of the esophageal hiatus.
The craniocaudal diameter has been found to vary around 1. Most authors have accepted that the structure of the esophageal hiatus is formed exclusively by muscle fiber bundles. Collis and Collis et al. On the other hand, an elliptical opening might correspond to an extensive tendinous origin. This author concluded that the posterior limit of the esophageal hiatus would invariably be muscular and that the preceding limit would be tendinous. Androulakis et al. However, these studies did not take into consideration the anatomical relationship between the esophageal hiatus and the presence of such collagen fiber bundles, with regard to delimiting this hiatus.
Ten human cadavers of male adults without macroscopic signs of trauma, surgical intervention or illnesses of the esophageal hiatus were used. From each cadaver, a block was removed containing part of the diaphragm muscle and surrounding tissues. The dissection exposed the abdominal and thoracic faces of the esophageal hiatus, from the central tendon to the main pillars of the diaphragm.
In order to adequately preserve the anatomy of the esophageal hiatus, the muscle diaphragm was affixed to a polystyrene board. With the aid of digital calipers the following measurements were made: distance between the vertices of the superior angle VSA and lower angle VIA of the esophageal hiatus; greatest transversal distance between the internal edges of the hiatus; thickness of the pillars; distance between VSA and the tendinous center; and distance between VIA and the median arcuate ligament of the muscle diaphragm Fig.
Photograph showing the distances measured in the esophageal hiatus. Greatest transversal distance of the esophageal hiatus. Distance between the vertex of the superior angle and tendinous center.
Distance between the vertex of the inferior angle and arcuate median ligament. Each of the pillars at the level of the hiatus was divided into six sections. These sections were embedded in paraffin, and histological sections of seven micrometers in thickness were made. The picrosirius, hematoxylin and Masson staining techniques were used. The statistical analyses were performed using the Origin 6.
In all the cadavers studied, the right pillar of the muscle diaphragm formed both the left branch and the lateral region of the right branch of the esophageal hiatus. The origin of the medial branch of the right branch was also predominantly the right pillar, but in four cases the origin of this region was the left pillar. Collagen fiber bundles of tendinous appearance Fig.
The length of the esophageal hiatus, measured as the distance between VSA and VIA, presented an average value of 4 cm, with only three occurrences below this average. Since the width of the esophageal hiatus corresponded to the greatest lateral transversal distance between its branches, the values were more evenly distributed: half of them below and half of them above the average Table II. The correlation between length and width of the hiatus was low Fig. In six cadavers, the right margin was thicker than the left, while in four, the margins had similar thicknesses Table III.
Regarding the distance between VSA and the central tendon of the diaphragm muscle, the values in the thoracic face were twice as high as in the abdominal face. In cases. Regarding the distance between VIA and the median arcuate ligament of the diaphragm muscle, the values were greater in the thoracic face than in the abdominal face.
In the cadavers in which there were collagen fiber bundles of tendinous appearance, there were two occurrences of raised values in both faces of the hiatus Table V. Curve of correlation of Pearson enters the measures between VIA and the arcuate median ligament in the faces abdominal and thoracic.
There has been much controversy between different authors' findings concerning the anatomy and morphofunctional aspects of the esophageal hiatus. Low participation by the left pillar in forming the margins of the esophageal hiatus has been reported by several authors Cecconelo et al.
Most authors accept that the structure of the margins of the esophageal hiatus is formed exclusively by muscle fiber bundles. Nor did they establish any correlation between their findings and the anatomical characteristics of the esophageal hiatus. Most studies have assumed that the right margin of the esophageal hiatus is thicker than the left margin Allison; Pataro et al.
This finding seems to be uncommon in the literature. The presence of collagen fiber bundles seemed to influence the thickness of the margins of the esophageal hiatus. Meanwhile, the margins without collagen fiber bundles were thinner. In the present study, four cadavers had below-average margin thickness, while in two cadavers, the lengths and widths were greater than or equal to the respective averages.
However, the correlation between these variables was statistically low. Regarding the relationship between the anatomical esophageal hiatus and the tendinous center, some authors Allison; Marchand; Pataro et al. In the present study, this relationship was represented by the distance between the VSA and the tendinous center, and the values in the thoracic face were twice the values in the abdominal face.
These values were smaller when the margins that formed the esophageal hiatus structure contained collagen fiber bundles, and were larger in the margins without collagen fibers. Botha accepted that the distance between VIA and the median arcuate ligament would diminish with increasing age of the individual and that there would be a widening of the esophageal hiatus.
The values found for the distance on the face were higher than those of the thoracic abdominal face, with a statistically significant high degree of correlation.
The presence of collagen fiber bundles in the muscle structure that delimits the margins of the esophageal hiatus seems to modify some anatomical aspects of the hiatus. It is desirable to continue to investigate this subject in order to contribute towards knowledge of the physiopathology and related surgical characteristics of this region.
Allison, P. Reflux esophagitis, sliding hiatal hernia and the anatomy of repair. Androulakis, J. Contributions to the pathological anatomy of hiatal hernia. Basmajian, J. In: Basmajian, J. Botha, G. The gastro-oesophageal region in infants; observations on the anatomy, with special reference to the closing mechanism and partial thoracic stomach. Botros, K. Anatomical variations in the formation of the human oesophageal hiatus.
Bouchet, A. In: Bouchet, A. Buenos Aires, Panamericana, Bowden, R. The anatomy of the oesophageal hiatus. Carey, J. An anatomic study of the esophageal hiatus. Cecconelo, I. In: Pinotti, H. Rio de Janeiro, Atheneu, Collis, J.
The diaphragm and hiatus hernia. Anatomy of the crura of the diaphragm and the surgery of hiatus hernia. Thorax, 9 3 , Costa, M. Pilares do diafragma. Anatomical investigation of the esophageal and aortic hiatuses: physiologic, clinical and surgical considerations.
Cunningham, D. In: Cunninghan, D. Barcelona, M. Marin, Dell'Isola, C. Anatomo-surgical findings on structure and function of the esophageal hiatus.
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