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Lucius D. Hill introduced the antireflux operation that bears his name in 1967. The principles of the operation are sound based on detailed anatomic dissections and perioperative physiologic testing. The Hill repair has proven to be highly effective and durable. The surgeon who learns the procedure and incorporates it into his or her repertoire is rewarded with expanded surgical options in both straightforward and complex cases, and a far better understanding of the function and anatomy of antireflux procedures. This chapter discussed the surgical technique, rationale, and outcomes of the Hill repair for the treatment of gastroesophageal reflux disease.

Despite documented success of antireflux surgery in controlling GERD in select patients, there remains a persistent incidence of failure requiring reoperation. Broadly speaking, the need for reoperation can be broken into three general categories, errors in diagnosis or patient selection, intraoperative errors, or the natural history of the antireflux operation itself or the condition being treated. When evaluating a patient for possible reoperative antireflux surgery, there are a variety of ways to approach the management, both determining whether to undertake a redo, and what operation to perform. These decisions depend on the timing of the development of recurrent symptoms or problems and the pattern of failure. Patterns of failure include, fundoplication disruption, recurrent or development of new hiatal hernia, tight fundoplication or crural stenosis, slipped fundoplication, and a fundoplication that is either too loose or misplaced at the time of initial surgery. Failure of antireflux surgery and the pattern of failure can usually be suspected based on presenting symptoms, either recurrent or new. A directed work-up including anatomic and functional studies should identify the failure pattern and guide decision-making about reoperation. Careful technique at the time of reoperation can result in a high rate of success of both resolving presenting symptoms and providing durable control of GERD. Understanding the patterns of failure can help guide improvements in technique to minimize future failure.

Reflux esophagitis without good response to medical therapy, whether or not an anatomical hiatus hernia is present. If a previous operation has been performed at the esophagogastric junction for reflux, a transthoracic or thoracoabdominal approach is preferred. Stein and DeMeester summarize their indications for an antireflux operation as follows: 1) Persistent or recurrent symptoms and/or complications after 8 to 12 weeks of intensive acid suppression therapy, and 2) Increased esophageal exposure to gastric juice on 24 hour esophageal pH monitoring, and 3) Documentation of a mechanically defective lower esophageal sphincter on manometry.