Guidelines Summary
In June 2013, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) issued guidelines for the diagnosis and management of hiatal hernia. [22, 23]
Strong recommendations include the following:
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Various tests can diagnose hiatal hernia but should be done only if they will change clinical management
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In the absence of reflux disease, repair of a type I hernia is unnecessary
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All symptomatic paraesophageal hiatal hernias (types II-IV) should be repaired, especially in the presence of acute obstructive symptoms or volvulus
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Acute gastric volvulus requires stomach reduction, with limited resection if needed
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To minimize poor outcomes, postoperative nausea and vomiting should be treated aggressively
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A transabdominal or transthoracic approach can effectively repair hiatal hernia
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The laparoscopic approach is as effective as (and has markedly less morbidity than) the open approach and is preferred for most hiatal hernias
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During paraesophageal hiatal hernia repair, the hernia sac should be dissected away from mediastinal structures
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Use of mesh for reinforcement of large hiatal hernia repairs is linked to lower short-term recurrence rates
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Hiatal hernia repair must return the gastroesophageal junction to an infradiaphragmatic position
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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)
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Gastropexy may safely be used in addition to hiatal repair
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In selected patients, gastrostomy tube insertion may facilitate postoperative care
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As early postoperative dysphagia is common, adequate caloric and nutritional intake are important
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In asymptomatic patients, routine postoperative contrast studies are unnecessary
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Experienced surgeons can safely perform laparoscopic revisional surgery
Weak recommendations for pediatric patients include the following:
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Symptomatic hiatal hernias should be surgically repaired
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A laparoscopic approach is feasible
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Hernia age or size is not an absolute contraindication to laparoscopy
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Gastroesophageal reflux (GER) should be addressed by a concomitant antireflux procedure
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The current standard of care is either hernia sac excision or disconnection from the crura
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Hiatal dissection should be minimal to reduce the risk for postoperative paraesophageal hernia after fundoplication
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Plication of the esophagus to the crura may reduce recurrence in children
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Hiatal Hernia. Figure 1 shows the normal relationship of the gastroesophageal (GE) junction, stomach, esophagus, and diaphragm. Figure 2 shows a sliding hiatal hernia, in which the stomach immediately below the GE junction is seen to prolapse through the diaphragmatic hiatus into the chest. Figure 3 shows a paraesophageal hernia in which the cardia or fundus of the stomach prolapses through the diaphragmatic hiatus, leaving the GE junction within the esophageal cavity.
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Hiatal Hernia. These anteroposterior (left) and lateral views (right) on a chest radiograph showing a large hiatal hernia. Courtesy of David Y Graham, MD.
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Hiatal Hernia. This barium study shows a sliding hiatal hernia: The gastric folds can be seen extending above the diaphragm. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. A paraesophageal hernia is seen on an upper gastrointestinal radiograph series. Note that the gastroesophageal (GE) junction remains below the diaphragm. Courtesy of David Y Graham, MD.
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Hiatal Hernia. A paraesophageal hernia is seen on a barium upper gastrointestinal radiograph series. The mucosal folds are seen going up into the chest, next to the esophagus. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. This image is a barium radiograph view of a large paraesophageal hernia. GE = gastroesophageal. Courtesy of David Y Graham, MD.
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Hiatal Hernia. This barium radiograph shows a large paraesophageal hernia in which the entire stomach is seen in the chest cavity. Courtesy of David Y Graham, MD.
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Hiatal Hernia. These barium studies show gastric volvulus as the herniated stomach undergoes rotation. This situation requires surgical intervention. Courtesy of David Y Graham, MD.
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Hiatal Hernia. A retrograde view of a hiatal hernia seen at endoscopy shows the gastric folds to the left of the scope shaft extending up into the hernia. Courtesy of David Y Graham, MD.
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Hiatal Hernia. Inderpal S Sarkaria, MD, discusses the options for paraesophageal hernia repair. Courtesy of Memorial Sloan-Kettering Cancer Center.
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Hiatal Hernia. This image shows a Linx device in place during laparoscopic surgery. Courtesy of Shawn S Groth, MD, MS, FACS.
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Hiatal Hernia. This image demonstrates a Linx device in place on x-ray. Courtesy of Shawn S Groth, MD, MS, FACS.
