Anatom

y
o The esophageal hiatus is formed by muscle fibers of the right
crus of the diaphragm, with little or no contribution from the
left crus.

o These fibers overlap inferiorly where they attach over and

along the right side of the median arcuate ligament, which is
attached to the lateral aspects of vertebral bodies.

o The phrenicoesophageal ligament is formed by fusion of the

endothoracic and endoabdominal fascia at the
diaphragmatic hiatus. This ligament inserts onto the
esophagus and holds the distal esophagus
 Hiatus hernia
• It is defined as “The herniation of abdominal contents into the chest through the esophageal hiatus”.

May occur as a result of a

I. Congenital defect

II. Trauma

III. After antireflux or other hiatal hernia operations

Hiatal Hernia
Types
Type I
Sliding hernia. The GE
junction is located above
the level of the diaphragm
by upward herniation of
the cardia into the
posterior mediastinum.
This is the most common
type and frequently
associated with GERD.
Type II
The GE junction and cardia
of the stomach are
located below the level of
the diaphragm; however,
the fundus of the stomach
has entered the
mediastinum adjacent to
the GE junction. This is a
true paraesophageal
hernia (PEH) and
represents the rarest
type.
Type III
Hernias are a combination of
Types I and II, with both the GEJ
and the fundus herniating
through the hiatus. The fundus
lies above the GEJ also called
giant PEH. This is the most
common type found when
surgical intervention is required.
Type IV
Similar to type III with the
addition of another
structure herniated into
the mediastinum, such as
colon, spleen, small bowel,
liver, or pancreas.
Epidemiolog
y
• Sliding hernia greater then 95%

• PEHs account for approximately 5% to 15%.

• 3% to 6% of all patients undergoing surgical repair of hiatal hernias.

• Obesity, Kyphosis or scoliosis are risk factor for developing a hiatal hernia.

• In children, congenital defects are the most common cause of PEH.

Symptom
s• Dysphagia
• Early Satiety

• Regurgitation
• Respiratory Complications
Sig
•nAcute gastric bleeding
• One-third of patients with PEHs are anemic due to
Saddle or Cameron’s lesions
• Obstruction
• 30% of patients with PEHs presented with gastric
volvulus
• Strangulation
• Perforation
• infarction
Diagnosi
s
Chest x-
ray
• Barium study of the esophagus
helps establish the diagnosis with
greater accuracy .
 Endoscop
y
• Identify fibrotic stricture, esophageal neoplasm, epiphrenic diverticulum, barrett’s

esophagus or esophagitis.

• Identify intragastric ulcers and diagnosis GERD associated with hiatal hernia
CT
Scan
Esophageal manometry
TREATMENT
OPTIONS
• The goals of treatment are to relieve symptoms and prevent further complications.

• Reducing the gastroesophageal reflux will relieve pain.

• Other measures to reduce symptoms include:

o Avoiding large or heavy meals

o Not lying down or bending over immediately after a meal

o Reducing weight and stop smoking

• If these measures fail to control the symptoms, or complications occur, surgical repair of
the hernia may be necessary.
Endoscopic procedures

- Stretta procedure

- EsophyX
Surgical
Options
Open
I. Thoracotomy
II.Laparotomy
Minimally invasive
III. Laparoscopi
c
IV. Transthorac
ic
- Belsey Mark IV (2400
A) Anti-reflex procedure
V. - Nissen’s
fundoplication (360○P)
VI. - Toupet’s
fundoplication (270○ P)
VII. - Dor
Surgical
Options
• Neoesophagus
- Collis gastroplasty
• Shortening
• Gastropexy by placement of a
gastrostomy tube can be a useful adjunct
in poor operative candidates or in
emergency situations.

• Gastric bypass with crural repair

in severely or morbidly obese
Port Placement
Standardized Nissen
fundoplication
1. Left to right opening of the phreno-oesophageal ligament
2. Preservation of the hepatic branch of the anterior vagus nerve
3. Dissection of both crura
4. Transhiatal mobilization to allow approximately 3 cm of intra-abdominal oesophagus,
5. Short gastric vessel division to ensure a tension-free wrap
6. Crural closure posteriorly with non-absorbable sutures
7. Creation of a 1.5 to 2-cm wrap with the most distal suture incorporating the anterior muscular wall of the oesophagus.
8. Bougie 58fr placement at the time of wrap construction.
Intraoperative complication
• Pneumothorax
• Bleeding
• Esophageal or gastric perforation
• Vagal injury
Early Post-operative
complication
• Subcutaneous crepitance in chest, neck and even head
• Wound infection
• Atrial Fibrillation
• DVT
Long-term Post-operative
complication
• Dysphagia
• Belching
• Gas Bloat
• Pulmonary symptoms
• Weight loss
• Slipped Nissen
• Recurrence of PEH
Slipped Nissen
SAGES Guidelines for the Management of Hiatal Hernia 2013
Repair of a type I hernia in the absence of reflux disease is not necessary (+++, strong)

All symptomatic paraoesophageal hiatal hernias should be repaired (++++, strong), esp. acute

obstructive symptoms or volvulus. Acute gastric volvulus requires reduction of the stomach with limited

resection if needed. (++++, strong)

Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach (++++, strong).

During paraoesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal

structures (++, strong) and then preferably should not excised (++, strong)

The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term

recurrence rates (+++, strong)

A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux

A necessary step of hiatal hernia repair is to return the GEJ to an infra-diaphragmatic position (+++, strong). This length

can be achieved by combinations of mediastinal dissection of the oesophagus and/ or gastroplasty (++++, strong)

Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients. Gastropexy

may safely be used in addition to hiatal repair (++++, strong)

Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes (++, strong)

Gastrostomy tube insertion may facilitate postoperative care in selected patients (++, strong)

With early postoperative dysphagia common, attention should be paid to adequate caloric and nutritional
intake (+,

strong)
• Routine elective repair of completely asymptomatic PEH may always be indicated. Consideration for surgery

should not include the patient’s age and comorbidities. (+++, strong)

• During operations for Roux-en-Y gastric bypass, sleeve gastrectomy and the placement of adjustable gastric

bands, all detected hiatal hernias should no be repaired (+++, strong)

• . A fundoplication is not important during PEH repair. (++, strong)

• In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may be necessary

(++, strong)

• Recurrence can be reduced by extensive mediastinal oesophageal mobilization to bring the GEJ at least 2-3 cm

into the abdomen without tension (++, strong).

 Aftercar
e
• Diet & Medication

1. Liquids 1st-2nd week

2. Mashed/soft diet 2nd–4th week
3. Solids 5th-6th week
I. Small mouthfuls
II. Chew well
III. Swallow slowly
IV. Avoid tablets/capsules 6 weeks
Aftercar
e
• Activity

1. Walk as normal
2. Buildup physical activity over 6-8
weeks
3. Strenuous activity permitted after 6
weeks.
4. Avoid driving for 3-4 weeks
5. Sexual relations can resume when
comfortable
PROGNOS
IS
• Symptomatic relief post operatively greater than 80% .

• With or without the use of mesh, the recurrence rate of hiatal hernias is

between 20 and 40% even in large-volume centers.

• Operative mortality rate for emergent repair of incarcerated PEH is

50% .