Hiatus hernia

management
By

Dr. Muhammad Nawaz Anjum

FCPS, MRCSEd, Dip in MIS France
Associate Professor of Surgery
University College of Medicine
 Anatomy of the hiatus
• Esophageal hiatus is at the level of D 10
• Transmits
• Esophagus
• Anterior and posterior vagus nerve
• Esophageal branches of left gastric artery
• Accompanied veins
Anatomy of the hiatus
• Pherenoesophageal
ligaments
Hiatus hernia
• Herniation of the abdominal contents
through esophageal hiatus
• Sliding hiatus Hernia
• Rolling Hiatus Hernia
• Most common viscera is stomach

• Rarely colon and spleen could be part of

sac in rolling variety.
 Pathophysiology
• Size of the hiatus is not fixed.
• Narrows with increase in intraabdominal pressure normally
• Tear of the phrenoesophageal ligament with abnormal increase
in intrabdominal pressure.
• A hiatus hernia compromise reflux barrier,
• Reduced LES pressure
• Reduced esophageal clearance
• Transient LES episodes at night
Types of hiatus hernia
• Sliding Hiatus hernia
• Herniation of the stomach and the GE in
to chest
• 90 % of esophageal hernia

• Paraoesophageal hernia
• Herniation of the part of stomach through
hiatus with displaced GE junction
• 10% of all hiatus hernia
Types Hiatus
hernia
 Sliding hiatus Hernia
• Absence of intrabdominal length of
esophagus results in sliding hiatus hernia.

• Weakness of phrenoesophageal ligament

leads to widening of esophageal hiatus
allowing stomach to slide up in the chest.

• May or may not be associated with GERD.

• Symptoms depends upon competence of

LOS.
Sliding hiatus hernia
Symptoms of Sliding hiatus hernia
• May be asymptomatic
• Usually discovered incidentally during Upper GI endoscopy
• May presents with
• epigastric pain,
• retrosternal burning and
• regurgitation
• Symptoms are provoked by spicy and fatty foods if the patient has
associated reflux.
Investigation of sliding
hernia
• Upper GI endoscopy
• Barium swallow
• 24 hours pH monitoring if associated with severe
reflux
Indication of Surgery
• Failure of medical therapy
• Esophageal strictures
• Severe nocturnal aspiration
• Repeated chest infection due to aspiration
• Barret’s esophagus
Treatment of Sliding hernia
• Life style Modification
• Stop smoking
• Weight loss
• Elevate head of bed
• Last meal at least 3 hours before sleeping
• Smaller and more frequent meals
• Avoid too much alcohol, coffee and fizzy drinks
• Tension free life styles
• Regular exercise
Treatment of Sliding
hernia
• Asymptomatic cases do not required any
treatment.

• PPI for mild to moderated cases.

• Repair of esophageal hiatus by sutures.

• Nissan's fundoplication for hiatus hernia

associated with severe reflux
Laparoscopic repair of Sliding hernia
Laparoscopic Fundoplication
Other Fundoplication's
• Floppy Nissan’s Fundoplication
• Dor’s (Anterior) partial fundoplication
• Toupet’s( Posterior) partial fundoplication
Paraoesophageal (Rolling Hiatus Hernia)
• This is a true hernia due to rolling of the
stomach in to chest.
• Isolated paraoesophageal hernia are rare
• Vast majority are mixed hernia in which
• Cardia is displaced in to the chest.
• Greater curve of the stomach rolled in to
mediastinum.
• Colon and small intestine might lie in the chest
• There is always an element of volvulus of
stomach
 Paraoesophageal (Rolling Hiatus Hernia)

• GE junction remains in normal position

• Fundus of the stomach rolls in to chest

• Angle of His is maintained

Paraoesophageal Hernia( Symptoms)
• Most symptoms are due to
• twisting of stomach and
• distortion of the stomach.
• Dysphagia is common
• Chest pain from distension of the stomach.
• Pain may be relieved by large belch.
• Symptoms of GERD.
• Emergency presentation with
• Strangulation,
• gastric perforation
• and gangrene
Paraoesophageal Hernia
( Investigation)
• Chest Xray; gastric bubble and
fluid level in the chest.

• Barium meal ; Best investigation

• CT scan of the chest.

• Endoscopy.
Hiatus hernia on x-ray
CXR for picture of Rolling Hiatus Hernia
• Gastric bubble
• Fluid level in the chest
Barium swallow (Rolling Hiatal Hernia)
Barium Swallow of
Hiatus hernia conti..
Hiatus Hernia CT
Pictures
CT pictures of HH
Endoscopic picture of rolling HH
Paraoesophageal Hernia( Treatment)
• All symptomatic rolling hernias needs surgical treatment.
• There is risk of 1 % per for asymptomatic hernias to become
symptomatic annually.
• Surgical treatment involves.
• Reduction of the hernia
• Excision of the sac
• Reducing the crural defect
• Measure to keep stomach reduced like fundoplication or mesh
• Repair can be performed laparoscopically or by open method.
Laparoscopic Mesh repair of HH
Laparoscopic Mesh repair of HH
Strangulated Paraoesophageal Hernia
• Keep the patient NPO
• Nasogastric tube to
• Aspirate the stomach
• Relive the pain and
• Distension
Complications of surgery
• Infection
• Bleeding
• Pneumothorax/hemothorax
• Pneumonia/empyema
• Mediastinitis
• DVT
• PE
• Abdominal hollow viscus injury
• Lung injury
Thank you