This document discusses hiatal hernia, including: 1. It classifies hiatal hernias into four types, with type I being the most common sliding hernia and types II and III being paraesophageal hernias. 2. Symptoms vary but can include chest pain, dysphagia, and regurgitation. Paraesophageal hernias pose greater risks of incarceration and strangulation. 3. Diagnosis involves imaging like barium swallow and endoscopy to visualize the GE junction. 4. Treatment is usually surgical repair, with laparoscopic being preferred over open approaches. The hernia sac is excised and the crura are reapproximated.

1. HIATUS HERNIA
B D SONI
SIDDS , SDMH

2. • Physiology of LES
• Classification of Hiatus hernia
• Prevalence
• Symptoms
• Complication
• Diagnosis
• Treatment

3. PHYSIOLOGY
- LES
High pressure zone(24 mmHg)
Physiological entity
Many factors contribute

4. • Intrinsic esophageal musculature- tonic
contraction

5. • Sling fibre of cardia
• Crural opening (Diaphragm)

6. • Transmitted abdominal pressure over the
abdominal part of esophagus
• AIM – Restoration of at least 2.5 cm length of
distal esophagus within the abdominal cavity

7. Classification
• Type I – sliding (Most common)
• Type II –Rolling Hitus hernia
• Type III –combination of I and II (mixed)
• Type IV
Type II and Type III –collectively known as
“paraesophageal hernia”

9. Type I
• Most common type which is associated with
GERD
• GEJ is not maintained in the abdominal cavity by
the phrenoesophageal ligament (membrane)
• Hence cardia migrates back and forth between
the posterior mediastinum and peritoneal cavity
• Stomach remains in its usual longitudinal
alignment

10. Type I
• Development of a hiatal hernia appears to be
related to –
1. Age
2.Structural deterioration of the
phrenoesophageal membrane over time
(Due to repetitive upward stretching of the
phrenoesophageal membrane during
swallowing, as well as the combined forces of
negative intrathoracic pressure and positive
intraabdominal pressure )

11. Type I
• Majority of patients with Sliding hiatal hernia
are asymptomatic
• Prevalence and size of the sliding hiatal hernia
correlate with increasing severity of GERD

13. Phrenoesophageal membrane
• Continuation of endoabdominal fascia , lies
just superficial to peritoneal reflection at hitus
& continue in to mediastinum
• Ligament consists of loose connective tissue,
collagen fibers, and elastic lamellae

14. Type II
• A “true” paraesophageal hernia—is defined by
a normally positioned intraabdominal GE
junction, with the upward herniation of the
stomach alongside it

15. Type II
• The phrenoesophageal membrane is not
weakened diffusely but focally

16. Type III
• “mixed” hernia, and is characterized by the
displacement of both the GE junction and a
large portion of the stomach cephalad into the
posterior mediastinum

17. • A paraesophageal hernia develops when there
is a defect, possibly congenital, in the
esophageal hiatus anterior to the esophagus.
• The persistent posterior fixation of the GE
junction is the essential difference between a
paraesophageal hernia and a sliding hiatal
hernia.

18. • PEH are recognized complication of surgical
dissection of hiatus as occur during antireflux
procedure, esophagomyotomy, or partial
gastrectomy
Peter J kahrilas Clinc gastroentelogy NIH 2008

19. Type IV
• In a type IV hernia, the esophageal hiatus has
dilated to such an extent that the hernia sac
also contains other organs such as the spleen,
colon, or small bowel
• Because of this altered anatomy, bowel
obstruction and other complications may
develop
• There could be associated laxity in the
gastrocolic and gastrosplenic ligaments
• This laxity can give rise to stomach volvulus

20. Stomach volvulus
• In organoaxial volvulus,
the greater curvature of
the stomach moves
anterior to the lesser
curve, along the axis of
the organ.
• In mesentericoaxial
volvulus, which is less
common, the stomach
rotates along its
transverse axis.

21. PREVALENCE
• The actual prevalence of hiatal hernia in the overall
population is not known as most patients are
asymptomatic
• Majority of cases identified are incidental radiographic
findings
• Greater than 95% of hiatal hernia are type I or sliding
hernias. Less than 5% are paraesophageal hernias.
• Of all paraesophageal hernias, type III are the most
common, accounting for 90% of cases, type IV are the least
common, occurring in only 2% to 5% of all paraesophageal
hernias.
• Women are four times more likely to develop a
paraesophageal hernia than men.
• incidence increases with advancing age. (PEH -6th decade)

22. Symptoms
• More than 50% of patients with paraesophageal
hernias are considered to be asymptomatic
• Symptoms include
Chest pain
Epigastric pain
Dysphagia
Postprandial fullness
Heartburn
Regurgitation
Vomiting
Weight loss
Anemia
Respiratory symptoms/Aspiration

23. symptoms

24. Symptoms
• Compared to a sliding hiatal hernia, symptoms
of dysphagia and postprandial fullness are
more common with a paraesophageal hernia
• Heartburn and regurgitation that commonly
are associated with a sliding hiatal hernia

25. Complication
• More common with PEH type III and Type VI
• Most serious complications of PEH are
incarceration with obstruction of the stomach
and gastric strangulation
• Gastric dilation can lead to ischemia,
ulceration, perforation, and ultimately sepsis
• Borchardt triad consists of chest pain,
retching with the inability to vomit, and the
inability to pass a nasogastric tube-
incarcerated intrathoracic stomach

26. Complication
• Bleeding - Hematemesis or anemia is evident
in about one-third of patients with
paraesophageal hernias (Due to ischemia or
from Cameron ulcer)
• Pulmonary complication- aspiration
pnemonitis/lung abscess/ pulm fibrosis

27. Cameron ulcer
• Linear ulcers are due to constant abrasive forces created as the
stomach rubs against, or is pinched by, the diaphragmatic
hiatus
• The most common location of these mucosal ulcerations is on
the lesser curve of the stomach at the diaphragmatic hiatus
• These lesions are seen during endoscopy in 5% of patients
with known hiatal hernias
• The risk of having Cameron lesions increases with hernia size
• Cameron lesions can be associated with intermittent bleeding,
Anemia secondary to bleeding from a paraesophageal hernia
• They resolve in 92% of the patients after surgical repair.

28. Complication

29. DIAGNOSIS AND PREOPERATIVE
EVALUATION
• Physical examination can be remarkable for
decreased breath sounds or dullness to
percussion in the left chest
• Bowel sounds can often be auscultated in the
chest in a type IV hiatus hernia
• 2 modalities- radiography, endoscopy

30. Radiography
• CXR- opacity in the left chest, or an air-fluid
level behind the cardiac silhouette (Lat View)
• A nasogastric tube coils in an intrathoracic
stomach
• CT scans show these anatomic abnormalities
with much more precision, also can determine
if other abdominal organs have migrated
above the diaphragm ( Type IV)

33. Radiography
• The barium esophagram provides the
diagnosis of a hiatal hernia in almost all cases
• Easiest way to determine the location of the
GE junction which can help to differentiate
between a type II and type III hernia.
• Location of GEJ can also be identified with
multislice coronal CT images.

36. Endoscopy
• Fiberoptic flexible endoscopy can readily
diagnose a PEH during the retroflexed
evaluation of GEJ
• Diagnostic findings of a type II Hernia include
a second orifice next to the GE junction, with
gastric rugal folds extending up into the
opening.
• A type III paraesophageal hernia shows a
gastric pouch extending above the diaphragm,
with the GE junction entering part way up the
side of this pouch

37. Endoscopy
• Endoscopy can also identify other intraluminal
abnormalities, including ulcerations, gastritis,
esophagitis, Barrett esophagus, or mucosal-
based neoplasms

39. Treatment
• PEH – anatomical abnormality, only surgery
• Symptoms of GERD may be alleviated by acid
suppression
• Symptoms caused by mechanical forces such
as ulceration, vomiting, and postprandial
chest pain respond only to surgical restoration
of normal anatomy

40. Endoscopic Rx
• For Pt with Highest Risk
• Stomach is partially reduced with a
gastroscope and fixed intraabdominally with a
double percutaneous endoscopic gastrostomy
technique, with or without laparoscopic
assistance
Ann Thorac Surg 74:333, 2002

41. Indication
• Repair of a type I hernia in the absence of
reflux disease is not necessary
• All symptomatic paraesophageal hiatal hernias
should be repaired particularly those with
acute obstructive symptoms or which have
undergone volvulus
• Routine elective repair of completely
asymptomatic PEH may not always be
indicated. Consideration for surgery should
include the patient’s age and comorbidities
• Acute gastric volvulus requires reduction of the
stomach with limited resection if needed

42. Surgery
• Transthoracic or transabdominal approach
• Recommended approach is “Laparoscopic”
due to the high success rate and lower
morbidity compared with a laparotomy or a
thoracotomy
• Open transabdominal approaches are
reserved for patients being converted from a
laparoscopic approach.

43. Adv:Laparoscopic Approach
• Laparoscopic paraesophageal hernia repair confers the
typical benefits of minimally invasive surgery—that is,
less blood loss and less third spacing of fluids, fewer
pulmonary complications, and a quicker recovery from
surgery
• Specially suitable for elderly & debilitated patients
• View of the operative field is magnified facilitating
precise identification of tissue planes and vessels
• The use of an angled laparoscope also allows
visualization of the mediastinum that cannot be
obtained via laparotomy

44. Technique
• Reduction of hernial centent with dissection
of sac & excision + reapproximation of crura +
supplementary antireflux procedure
360- degree (Nissen) fundoplication or a
posterior 240-degree (Toupet) fundoplication
is created

47. Outcome
• Thoracic Approach –
supradiaphragmatic repair was described by Dr.
Sweet in 1952
Approach involved reduction of the hernia,
plication or excision of the hernia sac, and
reapproximation of the hiatus with pledgeted
sutures from fascia lata if reinforcement was
necessary.

48. Outcome :Thoracic Approach
Patel et al 2004 (n=240)
• Collis gastroplasty – 96%
• Mortality rate – 1.7%
• Complication rate- 8.5%
• Anatomical Recurrence –
8%
• Reoperation – 3.3%
Maziak et al 2006 (n=94)
• Collis Gastroplasty -80 %
• Mortality rate – 2%
• Complication rate- 19%
• Anatomical Recurrence-
10%
• Reoperation-2%

49. Open Transabdominal Approach
• n =119
• Med Follow up 61.5 months
• Mortality rate was 1.7%,
• Complication rate 11.8%
• Symptomatic recurrences 11%
Williamson et al Lahey Clinic 2002

50. Laparoscopic approach
• n= 662
• Mortality rate 0.5%
• Radiographic recurrence was noted in 15.7%
(All recurrences were asymptomatic)
• Reoperation -3.2% ( 10 yr follow up)
Luketich JD, Nason KS, Christie NA, et al: Outcomes after a decade of laparoscopic
giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 139:395, 2010.

51. • Multiple studies also suggest that
laparoscopic repair of paraesophageal hernia
is successful, safe, and leads to a shorter
hospital stay, with lower costs and greater
patient satisfaction compared with the open
results

52. ROLE OF FUNDOPLICATION
• An antireflux procedure can help maintain the stomach in an
intraabdominal position
• The bulky nature of the wrap and/or the suture fixation to the
crura makes it more difficult for the stomach to reherniate
into the chest
• It is very difficult to preoperatively assess which patients will
have reflux symptoms once the hernia is reduced
• The functionality of the GE junction is likely to be
compromised by the operative dissection and reconstruction
necessary to reduce the hernia sac and repair the hiatus
• Failure to perform an antireflux procedure can lead to
symptomatic postoperative reflux in 20% to 40% of patients.

53. USE OF PROSTHETIC MESH
• In 2009, a survey of 275 members of the
Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) was performed
to investigate the use of mesh in their practice
• A total of 5486 hiatal hernia repairs were
reported, and 77% of those were repaired
laparoscopically.

54. MESH Hiatoplsty
• The most common indication for use of mesh was
an increased hiatal defect size, and the most
commonly used types of mesh were
nonabsorbable polytetrafluoroethylene (PTFE)
and polypropylene
• The failure rate that was reported was 3% and
seemed to be more commonly associated with
biodegradable mesh. The stricture rate was 0.2%.
The erosion rate was 0.3%. Stricture and erosion
were most frequently seen with nonabsorbable

55. • Giant hiatus hernia-
Giant hiatal hernia characterized by >1/3rd of
stomach migration with or without other
organ.
The laparoscopic hiatoplsty with antireflux
surgery is a safe and effective procedure to
repair giant hiatal hernia
Marano et al, BMC surgery 2014

56. Thanks