Hiatal Hernia Repair

Lev Khitin, md and David M. Brams, md



Indications for Procedure


Repair of Paraesophageal Hernia



Alternative Procedures



References introduction

The history of surgery for hiatal hernia and gastroesophageal reflux disease (GERD) has paralleled our gradual understanding of the physiological features of the esophagus. The association between GERD and esophagitis was not established until the 1940s, and much controversy arose concerning the relationship between hiatal hernia and GERD. Initial attempts at simply reducing the hernia by closing the crura proved to have unac-ceptably high failure rates. The Allison repair, introduced in 1951, involved mobilization of the distal esophagus with placement of the gastroesophageal junction within the abdomen and repair of the crura. This operation had a high recurrence rate, and subsequently several attempts were made at both fixing the gastroesophageal junction within the abdomen and wrapping the gastric fundus around the distal esophagus (fundoplication) to create an antireflux valve (1).

The most commonly performed hiatal hernia repair is the Nissen fundoplication. This was first performed in 1937 in a patient with a perforated ulcer of the gastric cardia in an effort to protect the repair. Because this patient subsequently had no evident reflux, Nissen performed this operation purposefully in patients with GERD. Other fundopli-cations that have become eponymic were subsequently developed, applied, and reported; but modifications of the Nissen fundoplication are currently the most widely used operations for GERD and hiatal hernias, (see Chapter 4, Table 1) (1,2).

From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ

Type Paraesophageal Hernia
Fig. 1. Type II hiatal or pure paraesophageal hernia: coronal section. Gastroesophageal junction is in normal intrabdominal position.

The term hiatal hernia refers to the protrusion of any structure other than the esophagus through the esophageal hiatus of the diaphragm and generally refers to a sliding hiatal hernia or a paraesophageal hiatal hernia. The most generally accepted nomenclature of hiatal hernia includes four principal categories. Type I, or sliding hiatal hernia, accounts for more than 90% of all hiatal hernias (see Chapter 4, Fig. 4). The esophagogastric junction is displaced through the hiatus into the mediastinum because of circumferential weakening of the phrenoesophageal membrane. Eighty percent of patients with GERD have type I hernia. Type II, or paraesophageal hernia, accounts for less than 5% of hiatal hernias (Figs. 1 and 2). Type II hernia occur more commonly in an older population than do sliding hiatal hernia. The esophagogastric junction remains fixed below the diaphragm, and the gastric fundus herniates through the defect into the mediastinum. Type III is a combination of both types I and II hernia (Fig. 3). Components of both sliding and paraesophageal hernia are present. It is seen in more than 5% of patients. Finally, Type IV is comprised of anatomically complex hiatal hernias. In addition to sliding and paraesophageal components, Type IV hernia contain other viscera such as the colon, omentum, small intestine, pancreas or spleen (Figs. 4 and 5) (2,3).

Other rare hernias may occur in the hiatal region, including parahiatal hernias that can be differentiated from types I through IV in that there is a separate extra-hiatal diaphragmatic defect in which intervening normal crural muscle tissue is present. They are rarely seen and may be associated with previous trauma. Additionally, congenital diaphragmatic hernias (Bochdalek—posterolateral or Morgagni—retrosternal) are more likely to present in childhood but may not be found until much later in life (2-4).

Hernia Hiatal
Fig. 2. Type II hiatal or pure paraesophageal hernia: upper gastrointestinal contrast study.
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