Hiatal Hernia Types, Symptoms, Diagnosis, Management and Complications

1. Hiatal Hernia
Types and Management
Advanced Laparoscopic in Robotic and Bariatric Surgery
King Saud University Medical City
22nd October, 2018
Ibrahim Abunohaiah
R1, Urology

2. HIATAL HERNIA
• The distal esophagus is held in position by the
phrenoesophageal membrane, a fusion of the
endothoracic and abdominal transversalis fascia at
the diaphragmatic hiatus.
• A hiatal hernia is present when a lax or defective
phrenoesophageal membrane allows protrusion of
the stomach up through the esophageal hiatus of
the diaphragm.

4. Epidemiology of Hiatal hernia
• Most common abnormality reported in upper
gastrointestinal (GI) radiographic studies.
• An estimated 10% of the adult population in the
United States has a hiatal hernia.
• Most hiatal hernias are asymptomatic; however, an
estimated 5% of patients with a hiatal hernia have
symptoms related to persistent gastroesophageal
reflux (GER) disease.

5. Types of Hiatal hernia
• The type of hiatal hernia is defined by the location
of the gastroesophageal (GE) junction and the
relationship of the stomach to the distal
esophagus.

6. Type I or sliding hiatal hernia
• In type I the phrenoesophageal membrane is intact
but lax, thereby allowing the distal esophagus and
gastric cardia to herniate through the esophageal
hiatus and placing the GE junction above the
diaphragm.
• This is the most common type and is usually
asymptomatic.

7. Type II or paraesophageal hiatal
hernia
• It occurs when a focal defect is present in the
phrenoesophageal membrane, usually anterior and
lateral to the esophagus, which allows a protrusion
of peritoneum to herniate upward alongside the
esophagus.
• The GE junction remains anchored within the
abdomen, whereas the greater curvature of the
stomach rolls up into the chest along- side the
distal esophagus.

9. Type III hiatal hernia
• Type III represents a combination of types I and II.
• This type is more common than a pure type II and is
characterized by herniation of both the greater
curvature of the stomach and the GE junction into
the chest.

10. Type IV
• Type IV hiatal hernia occurs when abdominal
organs other than or in addition to the stomach
herniate through the hiatus.
• Typically, these hernias are large and contain colon
or spleen in addition to the stomach within the
chest.

11. Symptoms and Complications
• In patients with sliding (type I) hiatal hernias are
related to GE reflux.
• Paraesophageal and combined (types II, III, and IV)
hernias frequently produce post-prandial pain or
bloating, early satiety, breathlessness with meals,
and mild dysphagia related to compression of the
distal esophagus by the adjacent herniated
stomach.

12. Complications
• The herniated gastric pouch is susceptible to
volvulus, obstruction, and infarction and can
develop ischemic longitudinal ulcers with frank or
occult bleeding.

13. Diagnosis
• Chest x-ray.
• Barium swallow.
• Endoscopy.
• Esophageal manometry.
• CT scan.

14. Diagnosis

15. Diagnosis

16. Management
• Asymptomatic sliding hernias require no treatment.
• Medical management with H2- blocking agents or
proton pump inhibitors in patients with sliding
hernias and GER with mild esophagitis.
• Antireflux procedure and hiatal hernia repair.

17. References
• Washington Manual of Surgery 6th.
• Schwartzs Principles of Surgery, 10th Ed.