the Management of Hiatus Hernia

- Recommendations

Section 1:Diagnosis:

·  Hiatal hernia can be diagnosed by various modalities. Only investigations which will alter the clinical management of the patient should be performed, (Good practice statement).

·  We recommend upper endoscopy with or without barium swallow for patients with a hiatal hernia, particularly prior to operative intervention, (Good practice statement).

·  Esophageal manometry studies should not be used as a routine investigation for hiatal hernia, (Good practice statement).

·  We advise performing computed tomography (CT) scan for patients with suspected complications, (eg. volvulized paraesophageal hernia), (Good practice statement).

·  We advise against the use of pH testing for the diagnosis of hiatal hernia except in patients with sliding hiatal hernias that might benefit from antireflux surgery, (Good practice statement).

Section 2: Indications for surgery:

·  We recommend against repair of a type I hernia in the absence of reflux disease, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·  We recommend repair of all symptomatic paraesophageal hiatal hernias, particularly those with acute obstructive symptoms or which have undergone volvulus, (Strong recommendation, high certainty evidence, ⁽¹⁾).

·   We advise against routine elective repair of completely asymptomatic paraesophageal hernias, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·  For acute gastric volvulus, we recommend reduction of the stomach with limited resection if vascular impairment is suspected, (Strong recommendation, high certainty evidence, ⁽¹⁾).

Section 3: Technical Considerations:

·  Although open surgical repair could be done, we recommend laparoscopic hiatal hernia repair rather than open repair as it has a reduced rate of perioperative morbidity and is associated with shorter hospital stays than open transabdominal repair. It is the preferred approach for the majority of hiatal hernias, (Strong recommendation, high certainty evidence, ⁽¹⁾).

·  We recommend dissecting the hernia sac away from mediastinal structures during paraesophageal hiatal hernia repair, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·   We advise excision of the hernia sac after its dissection from the mediastinal structures, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·   We recommend the use of mesh for reinforcement of large hiatal hernia repairs to decrease the short term recurrence rates, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·   We advise performing fundoplication during repair of a sliding type hiatal hernia to manage reflux. Fundoplication is also advised during para-esophageal hernia repair, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·  We recommend returning the gastroesophageal junction to an infra-diaphragmatic position, as a necessary step of hiatal hernia repair, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·  Hernia reduction with gastropexy alone and no hiatal repair may be suggested as a safe alternative in high-risk patients but may be associated with high recurrence rates, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·   In high risk patients, if the circumstances allow, formal repair is preferred, (conditional recommendation, high certainty evidence, ⁽¹⁾).

Section 4: Repair of hiatal hernia during bariatric operations:

·   We advise repair of all detected hiatal hernias during bariatric operations, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

Section 5: Postoperative Management:

·   We recommend treatment of postoperative nausea and vomiting aggressively to minimize poor outcomes, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·   With early postoperative dysphagia, we recommend adequate caloric and nutritional intake, (Strong recommendation, very low certainty evidence, ⁽¹⁾).

·   We recommend against routine postoperative contrast studies in asymptomatic patients, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

Section 6:  Revisional Surgery:

·  We recommend revisional surgery in presence of experienced surgeons, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·  Revisional antireflux surgery is not indicated except in symptomatic cases and in the presence of anatomical cause that could explain patient’s complaint, (Good practice statement).

·  Roux-en-Y gastric bypass is a valid option as a revisional antireflux surgery even in non-obese patients, (Good practice statement).