Paraesophageal Hiatal Hernia

The esophageal hiatus is formed by the right crus and little or no left crus. The phrenoesophageal ligament, which holds the distal esophagus in place is formed by fusion by endothoracic and endoabdominal fascia at the esophageal hiatus.

CLASSIFICATION There are 4 types of hiatal hernias. The sliding hernia or type I is the most common.

Type I Hiatal Hernia The E-C junction moves through the hiatus to the visceral mediastinum. Increased abdominal pressure( pregnancy, obesity, or vomiting ) and vigorous esophageal contraction may contribute the development of the hernia. G-E reflux and esophagitis may occur due to loss of tone of the LES.

Type II Hiatal Hernia It is uncommon. The phrenoesophageal membrane is not weakened diffusely but focally. The gastric fundus protrudes through the hiatus.

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Type III Hiatal Hernia It is combined with type I and type II. It is frequently present when a type II hiatal hernia have been present for many years.

Type IV Hiatal Hernia It refers hernia of organs other than the stomach. The T-colon and the omentum are the most common involved. The spleen and the small intestine may be involved.

ANATOMY AND PHYSIOLOGY In a true paraesophageal hiatal hernia, the lower esophagus and the cardia remain fixed below the diaphragm in the posterior aspect of the diaphragmatic hiatus. The herniated organs are covered with a layer of the peritoneum that forms a true hernia sac, unlike the type I hiatal hernia, in which the stomach forms the posterior wall of hernia sac.

ANATOMY AND PHYSIOLOGY Complications are bleeding, incarceration, volvulus, obstruction, strangulation and perforation. Gastritis and ulceration have been seen. The ulcer are the result of poor gastric emptying and torsion of the gastric wall.

SYMPTOMS Many type I and type II hernia have few or no symptoms. Bleeding results from gastritis and ulcer can induce IDA, resulting in fatigue and exertional dyspnea. Postprandial discomfort may occur. The substernal fullness is often mistaken MI.

SYMPTOMS In type II hernia, G-E reflux and true dysphagia is uncommon. If vovulus occurs, severe pain and pressure in the chest or epigastic region. Fever, hypovolemic shock will be present if volvulus progresses and strangulation occurs. In this situation, mortality rate is 50%.

DIAGNOSIS The diagnosis is suspected first on the CXR. The most common finding is retrocardiac bubble with or without air-fluid level. In a giant hiatal hernia, the herniated organ may be found in the right thoracic cavity. D.D: mediastinal cyst or abscess, dilated obstructed esophagus, as end stage of achalasia.

DIAGNOSIS The barium study of the UGI confirms the diagnosis. Endoscopy and esophageal function test can detect the function of LES.

THERAPY There is no accepted medical treatment for hiatal hernia. Surgery is indicated to prevent complications. In type II hernia, if gastric volvulus or obstruction is present without toxic signs, NG decompression must be performed. The surgery is scheduled.

Operative Approaches The operation or operative approach is controversial. The principles of operation is reduction of the hernia, resection of the hernia sac and closure of the defect. It is easy to do intrathoracic dissection via thoracotomy. However, transthoracic reduction may lead to volvulus of the gastric body.

Operative Approaches Abdominal approach is also suggested. Additional procedures can be done, such as gastrotomy, which obviates the NG tube and decreases the risk of recurrent volvulus. Abdomional approach is difficult to do in type III hiatal hernia with G-E reflux and a foreshortened esophagus. Laparoscopic repair is also advocated.

Should a Antireflux Procedure Be Induced? It is controversial. It is indicated in patients with esophagitis by symptoms and endoscopy, with a hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring.

Operative Technique: Conventional Abdominal Approach The author prefers abdominal approach via upper midline incision. In type II hernia, the E-C junction is still in the abdomen, bounded posteriorly with a fibrous band. It is careful not to take down the attachment. Dissection is done on the lower 4 to 8 cm of the esophagus. The repair is done with nonabsorbable O sutures.

Operative Technique: Conventional Abdominal Approach Antireflux procedure is done when significant reflux esophagitis is present. A loose Nissen fundoplication is suggested by authors. If no fundoplication is performed then the stomach can be fixed by two methods: Hill suture plication and Stamm gastrostomy.

Operative Technique: Conventional Abdominal Approach Hill suture plication: 3 interrupted nonabsorbable sutures between lesser curve of the stomach and preaortic fascia Stamm gastrostomy: 2 functions 1. It eliminates the need of NG tube. 2. It fixes the stomach to the abdominal wall and to prevent volvulus.

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Operative Technique: Laparoscopic Approach

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Operative Morbidity and Mortality The operative mortality is less than 0.5%. If gasric volvulus occurs, the operative mortality is up to 14%. Pulmonary complication may be seen in patients with aspiration resulting from volvulus or obstruction. Complication of gastric stasis may result from edema of the released gastric segment.

Operative Morbidity and Mortality Other complications include gastric perforation, gastric bleeding, slipped Nissen fundoplication, small bowel obstruction and atelectasis.

RESULTS Long-term results are excellent. Simultaneous antireflux procedure is ineffective prophylaxis against recurrent herniation resultant G-E reflux. The long-term result after laparoscopic repair is unknown.

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