1. A 60-year-old female presents with chest pain below her sternum that radiates to her left shoulder. The pain is worsened after eating spicy foods and is relieved with omeprazole. 2. She likely has gastroesophageal reflux disease exacerbated by a hiatal hernia, allowing stomach contents to enter her esophagus. 3. Surgical repair of symptomatic hiatal hernias can effectively address her symptoms through approaches like fundoplication to reduce reflux.

1. 60 years old female H/O experiencing pain about an inch beneath her sternum
and sharp pains in radiating towards her left shoulder. It varies in intensity and is
increased immediately after eating spicy foods. After most meals, she c/o
suffering from mild heartburn. She is on course of Omeprazole, which alleviated
the symptoms, but they returned after a few days if she discontinue the PPI.

5. Dr Ibrahim Baloch
Resident Thoracic surgeon
CMH Rawalpindi , Pakistan

6. Anatomy
o The esophageal hiatus is formed by muscle fibers of the right
crus of the diaphragm, with little or no contribution from the
left crus.
o These fibers overlap inferiorly where they attach over and
along the right side of the median arcuate ligament, which is
attached to the lateral aspects of vertebral bodies.
o The phrenicoesophageal ligament is formed by fusion of the
endothoracic and endoabdominal fascia at the
diaphragmatic hiatus. This ligament inserts onto the
esophagus and holds the distal esophagus

7. Hiatus hernia
• It is defined as “The herniation of abdominal contents into the chest through the esophageal hiatus”.
May occur as a result of a
I. Congenital defect
II. Trauma
III. After antireflux or other hiatal hernia operations

8. Hiatal Hernia Types

9. Type I
It is also called a sliding
hiatal hernia, where the
GEJ migrates above the
diaphragm. The stomach
remains in its usual
longitudinal alignment and
the fundus remains below
the GEJ.

10. Type II
Hernias are pure
paraoesophageal hernias
(PEH); the GEJ remains in
its normal anatomic
position but a portion of
the fundus herniates
through the diaphragmatic
hiatus adjacent to the
oesophagus.

11. Type III
Hernias are a combination
of Types I and II, with both
the GEJ and the fundus
herniating through the
hiatus. The fundus lies
above the GEJ also called
giant PEH.

12. Type IV
Hiatal hernias are
characterized by the
presence of a structure
other than stomach, such
as the omentum, colon or
small bowel within the
hernia sac.

13. Epidemiology
• Sliding hernia greater then 95%
• PEHs account for approximately 5% to 15%.
• 3% to 6% of all patients undergoing surgical repair of hiatal hernias.
• Obesity is also a clear risk factor for developing a hiatal hernia.
• kyphosis or scoliosis may also lead to the development of PEH.
• In children, congenital defects are the most common cause of PEH.
• 30% of patients with PEHs presented with gastric volvulus.
• 29% mortality rate with nonoperative treatment.

14. Diagnosis

15. Chest x-ray
Retrocardiac air bubble with or
without an air-fluid level noted on
the lateral view of a standard chest
x-ray

16. • Barium study of the esophagus helps
establish the diagnosis with greater
accuracy .
• Typical findings include:
o Flattening of the base of the hernia
pocket, above the esophageal hiatus
o Stasis of barium in the herniated
segment above the esophageal hiatus
o Absent peristaltic waves in the
herniated pocket
o Irregularly shaped pouch as compared
to the smooth, pearshaped phrenic
ampula
o Identifiable gastric mucosal folds within
the pouch localization of the EGJ above
the diaphragm
o Upward the esophageal hiatus
o Retrograde filling of a herniated pouch
o A small fundus of stomach

17. Endoscopy
• Presence or absence of esophagitis.
• Diagnosis of GE reflux associated with PEH.
• Presence of barrett’s esophagus.
• Identify fibrotic stricture, esophageal neoplasm, or epiphrenic diverticulum.
• Identify intragastric ulcers, which may be the cause of the chronic anemia that many PEH present.

18. Esophageal
manometry
o Rule out concomitant esophageal dysmotility
disorders.
o Help the surgeon make an appropriate decision
regarding whether to perform a fundoplication and if
so what type of fundoplication (total or partial).
o Sometimes not possible to place the manometry
probe as a result of the PEH.

19. TREATMENT OPTIONS
• The goals of treatment are to relieve symptoms and prevent further complications.
• Reducing the gastroesophageal reflux will relieve pain.
• Other measures to reduce symptoms include:
o Avoiding large or heavy meals
o Not lying down or bending over immediately after a meal
o Reducing weight and not smoking
• If these measures fail to control the symptoms, or complications occur, surgical repair of
the hernia may be necessary.

20. Surgical Options
Surgical Options
- Laparoscopic vs. Open
- Total vs. Partial
- Nissen’s fundoplication (360○P)
- Toupet’s fundoplication (270○ P)
- Dor fundoplication (180○ A)
- Belsey Mark IV (Trans-thoracic)
Gastric bypass with crural repair in
severely or morbidly obese

21. Endoscopic procedures
- Stretta procedure -
radiofrequency
- EsophyX -
sutures

22. 1. Left to right opening of the phreno-oesophageal ligament
2. Preservation of the hepatic branch of the anterior vagus nerve
3. Dissection of both crura
4. Transhiatal mobilization to allow approximately 3 cm of intra-abdominal oesophagus,
5. Short gastric vessel division to ensure a tension-free wrap,
6. Crural closure posteriorly with non-absorbable sutures,
7. Creation of a 1.5 to 2-cm wrap with the most distal suture incorporating the anterior muscular wall of the oesophagus,
and
8. Bougie placement at the time of wrap construction.
Standardized Nissen fundoplication

23. Intraoperative complication
• Pneumothorax
• Bleeding
• Esophageal or gastric perforation
• Vagal injury

24. Early Post-operative complication
• Subcutaneous crepitance in chest, neck and even head
• Wound infection
• Atrial Fibrillation
• DVT

25. Long-term Post-operative complication
• Dysphagia
• Belching
• Gas Bloat
• Pulmonary symptoms
• Weight loss
• Slipped Nissen
• Recurrence of PEH
Slipped Nissen

26. SAGES Guidelines for the Management of Hiatal Hernia 2013

27. Only investigations which will alter the clinical management of the patient should be performed (+++, strong)
Repair of a type I hernia in the absence of reflux disease is not necessary (+++, strong)
All symptomatic paraoesophageal hiatal hernias should be repaired (++++, strong), esp. acute obstructive symptoms
or volvulus. Acute gastric volvulus requires reduction of the stomach with limited resection if needed. (++++, strong)
Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach (++++, strong).
During paraoesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal structures
(++, strong) and then preferably should not excised (++, strong)
The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term recurrence rates (+++,
strong)

28. A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux
A necessary step of hiatal hernia repair is to return the gastroesophageal junction to an infra-diaphragmatic position
(+++, strong). This length can be achieved by combinations of mediastinal dissection of the oesophagus and/ or
gastroplasty (++++, strong)
Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients. Gastropexy
may safely be used in addition to hiatal repair (++++, strong)
Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes (++, strong)
Gastrostomy tube insertion may facilitate postoperative care in selected patients (++, strong)
With early postoperative dysphagia common, attention should be paid to adequate caloric and nutritional intake (+,
strong)

29. • Routine elective repair of completely asymptomatic paraoesophageal hernias may always be indicated.
Consideration for surgery should not include the patient’s age and comorbidities. (+++, strong)
• During operations for Roux-en-Y gastric bypass, sleeve gastrectomy and the placement of adjustable gastric
bands, all detected hiatal hernias should no be repaired (+++, strong)
• . A fundoplication is not important during paraoesophageal hernia repair. (++, strong)
• In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may be necessary
(++, strong)
• Recurrence can be reduced by extensive mediastinal oesophageal mobilization to bring the GEJ at least 2-3 cm
into the abdomen without tension (++, strong).

30. Aftercare
• Activity
1. Walk as normal
2. Buildup physical activity over 6-8
weeks
3. Strenuous activity permitted after 6
weeks.
4. Avoid driving for 3-4 weeks
5. Sexual relations can resume when
comfortable

31. Aftercare
• Diet & Medication
1. Liquids 1st-2nd week
2. Mashed/soft diet 2nd–4th week
3. Solids 5th-6th week
I. Small mouthfuls
II. Chew well
III. Swallow slowly
IV. Avoid tablets/capsules 6 weeks

32. PROGNOSIS
• Symptomatic relief post operatively greater than 80% .
• Recurrence rate of PEHs ranges from 20-40%.
• operative mortality rate for emergent repair of incarcerated PEH is 50% .