Key Points

• The Hill repair is based on re-establishing normal anatomy by restoration of the gastroesophageal flap valve. Of all the current antireflux procedures, it is the only repair which firmly anchors the gastroesophageal junction to reliable structures within the abdominal cavity.
• The proven durability of the Hill repair is based on reliable fixation of the gastroesophageal junction within the abdominal cavity makes the Hill repair-viable and appropriate in patients with short esophagus and large paraesophageal hernias.
• The reconstruction of the gastroesophageal flap valve is the key element and works in conjunction with the lower esophageal sphincter and the intra-abdominal esophagus in maintaining the antireflux barrier.
• The Hill repair can be effectively performed open or laparoscopic with documented long-term symptom control.
• Hill sutures can be added as an adjunct to fundoplication or bariatric procedures to counteract axial tension and herniation thereby improving durability.

Gastroesophageal reflux disease (GERD) is the most common upper gastrointestinal problem affecting humans. GERD can be treated medically in the majority of patients. But for a portion of patients who fail medical management or who do not wish to be relegated to a lifetime of medication, surgery can be the treatment of choice. The goal of surgery is to restore the function of the antireflux barrier and control the symptoms and secondary complications of reflux.[1],[2]

The four most popular antireflux operations are the Nissen fundoplication, the Belsey Mark IV, the Toupet, and the Hill procedure. The Hill procedure is the only operation originating in the United States, developed by Dr. Lucius Hill in 1959 after extensive anatomic dissection to delineate the normal anatomy and structural integrity of the gastroesophageal junction. The Hill repair has undergone very little modification since its inception. This repair is the only one of the above-mentioned repairs not depending primarily on fundoplication for its effect; rather it is based on re-establishing normal anatomy by restoration of the gastroesophageal flap valve and firm fixation of the gastroesophageal junction (GEJ) to reliable intra-abdominal structures such as the preaortic fascia and the condensation of the crus. This unique aspect of the Hill repair makes it worthy of familiarity by any esophageal surgeon, not only as a procedure, but also as a window into the structural integrity and reconstruction of the gasroesophageal junction.