Hiatal Hernias


Hiatal Hernias

  1. Anatomy of the Gastroesophageal Junction
    1. Phrenoesophageal Ligament
      • formed by the fusion of the endothoracic and transversalis fascia
      • anchors the distal end of the esophagus to the diaphragm
      • with each swallow, contraction of the longitudinal muscle of the esophagus shortens the esophagus and stretches the phrenoesophageal ligament
      • with each swallow, the gastric cardia is also pulled up through the esophageal hiatus, resulting in physiologic herniation
      • the repetitive stress of swallowing, as well as abdominal straining and vomiting, subjects the phrenoesophageal ligament to constant wear and tear

      Anatomy of the Phrenoesophageal Ligament
  2. Classification and Pathophysiology

    3. Classification of Hiatal Hernias
    1. Type I : Sliding Hiatal Hernia
      • accounts for 95% of hiatal hernias
      • characterized by the migration of the gastroesophageal junction (GEJ) above the diaphragm
      • fundus remains below the GEJ
      • the stomach remains in its usual longitudinal alignment
      • no true hernia sac
      • results from laxity of the phrenoesophageal ligament

      Type I Hiatal Hernia
    2. Type II, III, IV: Paraesophageal Hernias
      • true hernia with a hernia sac
      • results from a localized defect in the phrenoesophageal membrane
      • characterized by upward dislocation of the fundus through the defect in the phrenoesophageal ligament
      • also associated with laxity in the gastrocolic and gastrosplenic ligaments
      • the herniated stomach may rotate around its longitudinal axis (most common) or its transverse axis, resulting in a gastric volvulus

      Types of Gastric Volvulus
      1. Type II
        • least common paraesophageal hernia
        • fundus of the stomach migrates into the chest alongside the esophagus, while the GEJ remains fixed in the abdomen

        Type II Hiatal Hernia
      2. Type III
        • combination of type I and type II
        • accounts for 90% of paraesophageal hernias
        • both the fundus of the stomach and the GEJ migrate into the chest

        Type III Hiatal Hernia
      3. Type IV
        • occurs when another intraabdominal organ, most commonly the colon or spleen, migrates into the chest, along with the stomach
        • associated with a large defect in the phrenoesophageal ligament

        Type IV Hiatal Hernia Containing the Transverse Colon
        Type IV Hiatal Hernia Containing the Transverse Colon

  3. Clinical Presentation
    1. Sliding Hernia
      • most are asymptomatic or associated with reflux symptoms

    2. Paraesophageal Hernias
      • occurs primarily in older adults, with a median age of presentation between 65 – 75 years
      • many patients are asymptomatic, and the PEH is an incidental finding on chest x-ray or CT scan

        • CXR Showing a Large Retrocardiac Air Bubble
        Large Retrocardiac Air Bubble

      • intermittent obstruction of the GEJ may cause dysphagia, nausea, vomiting, chest pain, or abdominal pain
      • respiratory symptoms may occur from mechanical compression of the lung
      • anemia is common and is caused by ulceration of the mucosa at an area where the stomach folds back on itself (Cameron ulcer)
      • classic GERD symptoms are far less common than in sliding hernias
      • gastric volvulus may result in infarction, necrosis, perforation

  4. Diagnosis
    1. Barium Swallow
      • most sensitive test
      • can determine the anatomy and size of the hernia, orientation of the stomach, and location of the GEJ

      Organoaxial Gastric Volvulus
      Chronic Organoaxial Gastric Volvulus

Management of Paraesophageal Hernias

  1. Indications for Surgery
    • emergency repair is required for acute gastric volvulus, obstruction, strangulation, perforation, or uncontrolled bleeding
    • elective repair is indicated for dysphagia, early satiety, postprandial chest or abdominal pain, persistent vomiting, or GERD refractory to medical management
    • in patients over 65 with asymptomatic, or mildly symptomatic PEHs, the risk of surgery exceeds the risk of acute strangulation
    • most patients < 65, who are mildly symptomatic, may be treated with “watchful waiting”

  2. Preoperative Evaluation
    • UGI provides the most useful information about the anatomy of the hernia, orientation of the stomach, and location of the GEJ
    • endoscopy identifies Cameron ulcers, degree of esophagitis, Barrett’s esophagitis, cancer
    • manometry is valuable to determine the motor function of the esophagus – this will help the surgeon choose the type of antireflux procedure needed
    • pH testing is not routinely needed since it does not change the surgical management

  3. Surgical Approach
    1. Laparoscopic Versus Open Abdominal Surgery
      • recurrence rates are the same
      • length of stay, mortality, major morbidity are less with a minimally invasive approach
      • open surgery should be reserved for emergency cases, hostile abdomen, or contraindications to pneumoperitoneum

    2. Excision of the Hernia Sac
      • complete excision of the mediastinal hernia sac helps to prevent reherniation, but is potentially dangerous
      • injury to the pleura, esophagus, vagus nerves, or inferior pulmonary veins make complete excision of the sac risky, and so some surgeons omit this part of the procedure

    3. Esophageal Mobilization
      • sufficient mediastinal esophagus must be mobilized until 3 – 4 cm of intraabdominal esophagus can be obtained
      • occasionally, a Collis gastroplasty performed alongside a bougie is necessary to gain the requisite intraabdominal esophageal length

    4. Closure of the Hiatus
      • after the esophagus has been fully mobilized, the crura are closed inferiorly and posteriorly to the esophagus
      • this typically requires 3 or 4 interrupted nonabsorbable sutures
      • it is paramount that the crural closure be tension-free
      • if the hiatal defect is large, or the primary repair is under too much tension, then the crural closure can be reinforced with mesh

      1. Mesh Reinforcement
        • synthetic meshes are associated with esophageal erosion, fibrosis with stricture, and dysphagia
        • biologic meshes are associated with fewer complications then synthetic meshes
        • recurrence rates are decreased at 6 months for biologic mesh-buttressed repairs, but at 5 years the recurrence rates are equivalent to nonmesh repairs

        Mesh Reinforcement of Crural Closure
    5. Adding an Antireflux Procedure
      • many patients with PEH do not have reflux symptoms
      • many surgeons routinely do a fundoplication, even in asymptomatic patients
      • one potential benefit of routine fundoplication is improved gastric fixation below the diaphragm
      • another benefit is to prevent the development of reflux postop, which may occur after extensive esophageal dissection and mobilization
      • choice of wrap – partial or complete – is dependent on the adequacy of peristalsis

    6. Gastropexy
      • purpose is to decrease recurrence
      • usually done with tacking sutures to the anterior abdominal wall
      • in open surgery, historically a g-tube was used






References

  1. Sabiston, 19th ed., pgs 1033 – 1036, 1067 – 1083
  2. Cameron, 11th ed., pgs 9 – 14, 19 – 23, 27 – 36
  3. UpToDate. Hiatus Hernia. Kahrilas MD, Peter. Jan 14, 2019. Pgs 1 – 24
  4. UpToDate. Surgical Management of Paraesophageal Hernia. Rosen MD, Michael, Blatnik MD, Michael. March 2019. Pgs 1 – 37