Hiatal Hernia Guidelines

Updated: Sep 05, 2019
  • Author: Waqar A Qureshi, MD, FRCP(UK), FACP, FACG, FASGE; Chief Editor: Philip O Katz, MD, FACP, FACG  more...
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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:

  • 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