Hiatal Hernia Treatment & Management
- Author: Waqar A Qureshi, MD; Chief Editor: Julian Katz, MD more...
In June 2013, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the diagnosis and management of hiatal hernia.[8, 9]
Strong recommendations include the following:
Various tests can diagnose hiatal hernia but should be done only if they will change clinical management
In the absence of reflux disease, repair of a type I hernia is unnecessary
All symptomatic paraesophageal hiatal hernias (types II-IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus
Acute gastric volvulus requires stomach reduction, with limited resection if needed
To minimize poor outcomes, postoperative nausea and vomiting should be treated aggressively
A transabdominal or transthoracic approach can effectively repair hiatal hernia
The laparoscopic approach is as effective as (and has markedly less morbidity than) the open approach and is preferred for most hiatal hernias
During paraesophageal hiatal hernia repair, the hernia sac should be dissected away from mediastinal structures
Use of mesh for reinforcement of large hiatal hernia repairs is linked to lower short-term recurrence rates
Hiatal hernia repair must return the gastroesophageal junction to an infradiaphragmatic position
When repair is complete, the intra-abdominal esophagus should measure 2-3 cm or more (weak evidence), which can be achieved by mediastinal dissection of the esophagus or gastroplasty (strong evidence)
Gastropexy may safely be used in addition to hiatal repair
In selected patients, gastrostomy tube insertion may facilitate postoperative care
As early postoperative dysphagia is common, adequate caloric and nutritional intake are important
In asymptomatic patients, routine postoperative contrast studies are unnecessary
Experienced surgeons can safely perform laparoscopic revisional surgery
Weak recommendations for pediatric patients include the following:
Symptomatic hiatal hernias should be surgically repaired
A laparoscopic approach is feasible
Hernia age or size is not an absolute contraindication to laparoscopy
Gastroesophageal reflux (GER) should be addressed by a concomitant antireflux procedure
The current standard of care is either hernia sac excision or disconnection from the crura
Hiatal dissection should be minimal to reduce the risk for postoperative paraesophageal hernia after fundoplication
Plication of the esophagus to the crura may reduce recurrence in children
When hiatal hernias are symptomatic, acid reflux usually produces the symptoms. If the hernia itself is causing chest discomfort or other symptoms, surgery may be necessary.
When symptoms are due to GERD, the goals of treatment include prevention of reflux of gastric contents, improved esophageal clearance, and reduction in acid production. This is achieved in the majority of patients by a combination of the following:
Modifying lifestyle factors
Neutralizing acid or inhibiting acid production
Enhancing esophageal and gastric motility
The treatment of GERD is beyond the scope of this article and is discussed in Gastroesophageal Reflux Disease.
Large hiatal hernias may cause iron deficiency anemia regardless of whether Cameron ulcers are present. This anemia responds well to PPI therapy with surgery offering no clear advantage over medical therapy.
The goal of surgery is to remove the hernia sac and close the abnormally wide esophageal hiatus.
Surgery is necessary only in the minority of patients with complications of GERD despite aggressive treatment with proton pump inhibitors (PPIs). Because only a minority of patients with hiatal hernia have any problems, this represents a very small proportion of patients with sliding hiatal hernia; most patients with problems are managed medically.
By far, the majority of patients who would have undergone surgery in the past are managed successfully today with PPIs. However, young patients with severe or recurrent complications of GERD, such as strictures, ulcers, and bleeding, who cannot afford lifelong PPI treatment or would prefer to avoid taking medications long term, may be surgical candidates. Another group of patients who are surgical candidates are those with pulmonary complications, in particular, asthma, recurrent aspiration pneumonia, chronic cough, or hoarseness linked to reflux disease.
Most patients with a paraesophageal hernia remain asymptomatic. In this type of hernia, symptoms from acid reflux usually do not occur. Instead, the most common symptom is epigastric or substernal pain. Some patients complain of substernal fullness, nausea, and dysphagia. A significant proportion of patients with this type of hernia develop incarceration of the hernia and possible gastric volvulus, which can lead to perforation. If perforation occurs, the mortality rate is high. Because of this, many surgeons advise elective repair when the diagnosis is made.
A patient with a large hiatal hernia may experience vague intermittent chest discomfort or pain. The paraesophageal hernia may strangulate and frequently is operated on prophylactically to prevent this complication. Paraesophageal hernias may present in infants or adults as a potentially life-threatening complication of strangulation, and prompt surgical repair is key. When found in asymptomatic individuals, laparoscopic repair is often undertaken, with large defects in the diaphragm being closed with mesh.[10, 11, 12, 13]
Three major types of surgical procedures correct gastroesophageal reflux and repair the hernia in the process. They can be performed by open laparotomy or with laparoscopic approaches, which currently are being employed more frequently. These procedures offer relief of symptoms in 80-90% of patients.
In most cases, the procedure of choice is the one with which the surgeon is most familiar. These procedures carry low mortality and morbidity rates, lower than 15-20%.
A systematic review and meta-analysis of 4 trials comprising 406 patients found comparable results and outcomes between suture cruroplasty and prosthetic hiatal herniorrhaphy for large hiatal hernia closure. In another study consisting of data from 65 patients over nearly 2 decades, left thoracoscopic Collis gastroplasty-laparoscopic Nissen (Collis-Nissen) procedure and conventional laparoscopic Nissen fundoplication yielded similarly satisfactory results in uncomplicated patients with true short esophagus in the setting of gastroesophageal reflux disease and type III-IV hiatal hernia.
In another systematic study and meta-analysis of mesh (n = 673) versus suture (n = 521) cruroplasty during laparoscopic large hiatal hernia repair, data from 13 studies consisting of 1194 patients showed symptomatic improvement in most studies, with fewer odds of recurrence but not need for reoperation with mesh cruroplasty. However, the quality of the evidence for supporting routine use of mesh cruroplasty was low.
DeMeester et al found the Nissen procedure superior to the Belsey and Hill repairs with regard to symptom relief and prevention of reflux postoperatively (as judged by pH monitoring). Good long-term results have been reported for antireflux surgery, with adequate control of reflux in the range of 80% at 10 years.
See the video below for a discussion of surgical options for paraesophageal hernia repair.
Recurrent paraesophageal hernia (PEH) repair is performed for symptomatic recurrent hiatal hernia and/or reflux and appears to have similar outcomes to those of initial PEH, although increased operative time, blood loss, persistent symptoms, and need for Collis gastroplasty occurred more often in those who underwent revisional repair.
The Nissen fundoplication performed laparoscopically has gained popularity because of its lower morbidity and shorter hospital stay compared to the open procedure performed previously. Although a relatively high incidence of postoperative complications, such as dysphagia and gas bloating, are reported, DeMeester and Peters have shown that placing a larger bougie in the esophagus during this procedure, along with a shorter wrap and more complete mobilization of the stomach, have markedly reduced postoperative complications.[19, 20]
This procedure involves a 360° fundic wrap around the gastroesophageal junction. The diaphragmatic hiatus also is repaired.
A transthoracic approach may be used in patients who have had a previous Nissen wrap or those who have an irreducible hernia.
In a study involving 26 patients who underwent Nissen fundoplication, the use of permanent mesh following fundoplication resulted in symptom improvement in 23 patients (88.5%), with hernia recurrence reported by the remaining three patients (11.5%). No mesh erosions occurred during the mean 65-month follow-up period.
The Toupet procedure is a variant of the Nissen wrap and involves a 180° wrap in an attempt to lessen the likelihood of postoperative dysphagia.
This operation involves a 270° wrap in an attempt to reduce the incidence of gas bloating and postoperative dysphagia. It also is preferred when minimal esophageal dysmotility is suspected. To complete this operation, the left and right crura of the diaphragm are approximated.
In this procedure, the cardia of the stomach is anchored to the posterior abdominal areas, such as the medial arcuate ligament. This also has the effect of augmenting the angle of His and thus strengthening the antireflux mechanism.
Some surgeons then tack the stomach down in the abdomen to prevent it from migrating upwards again, or, they perform a temporary gastrostomy to help decompress the stomach and anchor it in place in the abdominal cavity.
An appropriate diet maintains an ideal body mass index. Obesity predisposes to reflux disease.
Burkitt et al suggest that the Western, fiber-depleted diet leads to a state of chronic constipation and straining during bowel movement, which would explain the higher incidence of this condition in Western countries.
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