A brief description of hiatus hernia and its management

1. HIATUS HERNIA
under the guidance of
Dr.M.Anand MS.FRCS.
Dr.A.Suvarchala MS.
Dr.TVSS.Nagababu MS.
Dr.Venkatnaidu MS.

2. • It is a type of hernia characterised by
protrusion of abdominal organs
especially stomach into chest cavity
through the oesophageal hiatus (T10) of
the diaphragm

3. RISK FACTORS
• Most common – obesity
old age
• Others:
major trauma
scoliosis

4. ETIOLOGY
• Increased intra abdominal pressure –
• heavy lifting
• frequent/hard coughing
• violent vomiting
• straining during defecation
• Trauma to the diaphragm
• Congenital anomalies

5. • Type 1 / sliding hiatus hernia :
• Upward displacement of GE junction into
posterior mediastinum
• Stomach remains in its usual longitudinal
alignment
• Prevalence and size correlate
with severity
of reflux disease.

6. • Type 2 / true PEH/rolling hernia:
• Normally positioned intraabdominal GE
junction with upward herniation of the
stomach alongside it.
• Develops when there is a defect
possibly congenital in the
hiatus anterior
to oesophagus
• Angle of his is maintained

7. • Type 3/ Mixed hernia:
• Displacement of both the GE
junction and a large portion of
stomach cephalad into posterior
mediastinum

8. • Starts as a sliding HH and over time
as hiatus enlarges and more of
fundus and body of stomach
herniate into chest

9. • Type 4 hernia:
• Hernia sac also contains other organs
such as the spleen , colon , or small
bowel.

10. PATHOPHYSIOLOGY
• Widening of the diaphragmatic crura at
oesophageal hiatus
• Stretching of phrenooesophageal membrane
• As the hernia enlarges phrenoesophageal
membrane balloons into posterior
mediastinum like a parachute.
• Adhesions develop between wall of sac and
surrounding structures

11. • Most common organ to herniate is the fundus
of stomach
• However entire stomach , spleen
,colon,pancreas, small bowel and omentum
can migrate.
• Gastric volvulus develops because of laxity in
stomach’s peritoneal attachments and
subsequent rotation of gastric fundus
• on organoaxial or mesenteric axis
• Risk of acute strangulation -1% per year

12. CLINICAL FEATURES
• type 1- most common – GERD
• Paraoesophageal hernias:
-Most common- gastroesophageal obstructive
symptoms –
- Dysphagia, odynophagia , early satiety
• Intermittent epigastric, chest pain secondary
to visceral torsion and distension leading to
ischemia of contents

13. • TYPE 2: most dangerous-
• mucosal ischemia - gastrointestinal bleeding
• -perforation
• Ulceration of gastric mucosa- CAMERON’S
ULCER – vertical riding ulcer
• Respiratory symptoms – SOB by mass effect of
hernia (type 3,4)

14. INVESTIGATIONS:
• IOC: CT thorax with upper abdomen (oral
contrast)
• Others:
• Barium oesophagogram
• Upper GI endoscopy
• Manometry
• Ambulatory pH monitoring

17. TREATMENT
• Type 1:
• Medical:
1. modifying lifestyle factors, stop somking
2. Antacids,PPI
3. Domperidone,metoclopromide,erythromycin
• Surgical: Elective Nissen fundoplication

19. • Operative repair of PEH:
1. THORACIC
2. ABDOMINAL
• Open
• laparoscopic

21. Key steps:
1. Reduction of hernia contents into abdominal
cavity by gentle traction
2. Left triangular ligament, gastrohepatic
ligaments ,phreno oesophageal ligaments cut
3. Divide gastrophrenic ligament and short
gastric vessels to to mobilise fundus and
expose left crus.
4. Complete excision of hernia sac from
posterior mediastinum

22. Most challenging – mobilising posterior sac
• Oesophagus and posterior vagus are closely
associated with sac posteriorly
• Pleura ,pericardium,aorta,inferior pulmonary
veins are closely associated with sac
• After sac is freed at hiatus an effort is made to
remove as much of hernia sac from
mediastinum as possible

23. 4. Mobilisation of distal oesophagus to achieve a
minimum 3 cm of intra abdominal oesophagus
length
5.The crura are reapproximated tension free with
interrupted non absorbable suture
if not possible-
• Close the hiatus under tension+reinforce with
biologic mesh
• Diaphragmatic relaxing incision + reinforce
with biological mesh

25. • 5. An antireflux operation -
• Severely ineffective motility /apersitaltic
oesophagus- TOUPET fundoplication
• Rest others- NISSEN fundoplication

26. Complications:
• Dysphagia – 3 weeks – mucosal oedema
• If more than 3 weeks – tight wrap, tight hiatus
closure , missed other motility disorders
• Gas bloat syndrome
• Disruption
• Slippage
• Perforation
• Rare- injury to spleen(1-5%),vagi,
pneumothorax .

27. References:
• Sabiston textbook of surgery
• Bailey and love 27th edition
• Srb surgical operations text and atlas
• internet

28. THANK YOU…