the Management of Hiatus Hernia

This guideline offers evidence-based recommendations on the targeted levels of Clinical practice guidelines and provide healthcare professionals with practical guidance on the diagnosis and treatment of diverticular disease and its complications.

·  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).

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

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

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

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

· 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).

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

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

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

· 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).

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

·  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).

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

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

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

·  With early postoperative dysphagia, we recommend adequate caloric and nutritional intake, (Strong recommendation).

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

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

·  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).