the Management of Hiatus Hernia

Hiatal hernia is a common disorder, ^{(4 & 5)}. It is characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the hiatus of the diaphragm.

Attempts began early in the last century to classify hiatal hernia into four subtypes, ⁽¹⁾.

Greater than 95% of hiatal hernias are Type I. Types II – IV hernias as a group are referred to as paraesophageal hernias (PEH), and are differentiated from Type I hernias by relative preservation of posterolateral phrenoesophageal attachments around the gastroesophageal junction, ⁽⁶⁾. Of the paraesophageal hernias, more than 90% are Type III, and the least common is Type II, ⁽³⁾. The term “giant” paraesophageal hernia appears frequently in the literature, though its definition is inconsistent. Various authors have suggested giant paraesophageal hernias be defined as all type III and IV hernias , but most limit this term to those paraesophageal hernias having greater than one third to one half of the stomach in the chest, ^{(7- 9)}. These guidelines are specific for each type of hiatal hernia since the implications of a hiatal hernia and the indications for repair differ between the sliding (Type I) hernias and for the paraesophageal hernias (Type II, III and IV). Cephalad migration of the gastroesophageal junction may result from weakening of the phrenoesophageal ligament. Depletion of elastin fibers leads to stretching of the ligament and proximal displacement of the gastroesophageal junction, ⁽¹⁰⁾.

Most cases of hiatal hernia are acquired rather than congenital. Other diaphragmatic hernias exist but are not included in this review. These include acquired hernias such as traumatic diaphragmatic hernias; the rare parahiatal hernias in which the hernia defect arises lateral to the crural musculature and not through the esophageal hiatus itself; iatrogenic diaphragmatic hernias such as those that misguided chest tubes or after thoracoabdominal incisions in which the diaphragm is taken down, ⁽³⁾; and congenital diaphragmatic defects such as posterolateral Bochdalek hernias and retrosternal Morgagni hernias.

Management is complex and based on multiple factors including size and type of hiatal hernia, degree of symptoms, and associated failure of symptom control by non-surgical means. Deciding whether to proceed with surgical repair of an asymptomatic hiatal hernia can be difficult, ⁽¹⁾. These guidelines aim to provide recommendations on the aforementioned dilemmas.