ШЛЯХИ УДОСКОНАЛЕННЯ ХІРУРГІЧНОЇ ТАКТИКИ ПРИ ГРИЖАХ СТРАВОХІДНОГО ОТВОРУ ДІАФРАГМИ

This paper presents a comprehensive retrospective analysis of a six-year experience in managing patients with hiatal hernia (HH), emphasizing both clinical outcomes and surgical innovations. Special attention is given to the technical execution of operative procedures, notably the author’s own methodology for precise dissection of the diaphragmatic crura and the lower third of the esophagus. These techniques are described in detail and paired with a comparative overview of fundoplication strategies tailored to anatomical and pathological characteristics of the hernia. The disease spectrum was classified by hernia type, and surgical outcomes—including the incidence and nature of complications—were examined with respect to variations in disease presentation and intraoperative decisions. A sustained upward trend in the frequency of surgical interventions was noted, highlighting the growing relevance of operative management in hiatal hernia cases. Diagnostic methods were evaluated, underscoring the potential of multidetector computed tomography (MDCT) to refine preoperative planning. The study specifically advocates for the routine quantification of the esophageal hiatus surface area and the angle of His - parameters shown to provide meaningful insight into disease severity and structural deformity. The analysis substantiates the importance of objectively selecting the optimal fundoplication technique. Although the conventional Nissen method is a well-established approach offering robust anti-reflux efficacy, it presents notable limitations: operative duration is extended by an average of 30 %, the dissection of the gastric greater curvature is more aggressive, and patients show a higher prevalence of postoperative dysphagia. In response to these drawbacks, a modified technique is proposed, combining Dor fundoplication with gastric fundus fixation to the diaphragmatic crura. This approach yields advantages in procedural efficiency and shortens hospitalization time, offering a safer and more cost-effective solution for select patient groups. Based on clinical evidence, the authors advocate a differentiated fundoplication strategy. For patients with a hiatal defect exceeding 10 cm or where excessive tissue tension is observed during cruroplasty, the Nissen method is recommended. In cases of small to medium-sized hernias, the fixation-based Dor modification is preferable. For type II paraesophageal hernias without gastroesophageal reflux disease (GERD), where hiatal zone mobilization enables full translocation of the stomach into the abdominal cavity, stable positioning of at least 3 cm of the esophagus below the diaphragm, and restoration of the acute angle of His—the need for fundoplication may be obviated entirely. The study concludes by calling for an update to current clinical guidelines and surgical protocols for HH treatment, promoting a patient-specific approach that aligns operative techniques with anatomical conditions and disease severity. Such modernization would improve treatment outcomes and streamline surgical decision-making in routine clinical practice, offering lasting benefits for both surgeons and patients.