From the Guidelines
Surgical repair is generally advised for symptomatic paraesophageal hernias, with laparoscopic repair being the preferred approach. The decision to operate depends on symptom severity and patient factors, but surgery is often necessary to prevent serious complications like obstruction, strangulation, or gastric volvulus. For asymptomatic patients with small hernias, watchful waiting with lifestyle modifications may be appropriate, including avoiding large meals, not lying down after eating, and elevating the head of the bed 1.
Key Considerations
- Symptomatic patients typically require surgical intervention, which involves reducing the hernia contents back into the abdomen, removing the hernia sac, closing the hiatal defect, and often performing a fundoplication (typically Nissen or Toupet) to prevent reflux 1.
- Mesh reinforcement may be used for large defects, with the mesh overlapping the defect edge by 1.5–2.5 cm, and can be fixed using tackers or transfascial sutures 1.
- Preoperatively, patients should optimize their health status, and postoperatively they'll follow a graduated diet starting with liquids and progressing to solids over several weeks.
- Pain management typically includes acetaminophen and limited opioids.
Surgical Approach
The laparoscopic approach is preferred for hemodynamically stable patients without significant comorbidities, as it facilitates early diagnosis of small diaphragmatic injuries and reduces postoperative complications 1. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. The decision about the best surgical approach depends primarily on the chronicity of the condition, the surgeon’s preferences and skills, and the local resources 1.
Postoperative Care
Postoperatively, patients will require close monitoring and follow-up to prevent and manage potential complications, such as recurrence, reflux, or wound infections. A multidisciplinary approach, including surgeons, gastroenterologists, and primary care physicians, is essential to ensure optimal outcomes and improve quality of life for patients with paraesophageal hernias.
From the Research
Treatment Options for Paraesophageal Hernia
The recommended treatment for a paraesophageal hernia depends on various factors, including the severity of symptoms, patient age, and overall health.
- Laparoscopic repair is a commonly recommended approach for treating paraesophageal hernias, as it is associated with low morbidity and mortality 2.
- This approach involves reducing the hernia content, excising the sac, closing the crura, and performing fundoplication (Dor or Nissen) 2.
- The management of complications in paraesophageal hernia repair is crucial, and various strategies have been described, including the management of leaks and perforations identified postoperatively 3.
Laparoscopic Repair
Laparoscopic repair of paraesophageal hernias has been shown to be safe and effective, with low recurrence rates and minimal complications 4.
- A study published in 2004 found that laparoscopic repair of large paraesophageal hernias was associated with a low incidence of recurrence and reoperation 4.
- Another study published in 2015 found that laparoscopic repair with anterior gastropexy was a viable option, with a favorable recurrence rate and minimal complications 5.
Elective Laparoscopic Repair
Elective laparoscopic paraesophageal hernia repair has been shown to lead to an increase in life expectancy over watchful waiting in asymptomatic patients 6.
- A Markov analysis published in 2024 found that elective laparoscopic hernia repair led to greater life expectancy than watchful waiting, particularly in women 6.
- The study suggested that all patients with a paraesophageal hernia, regardless of symptoms, should be referred for consideration of elective repair to maximize their life expectancy 6.
Key Considerations
When considering treatment options for paraesophageal hernia, it is essential to weigh the potential benefits and risks of each approach.
- The choice of treatment should be individualized based on patient factors, such as age, overall health, and severity of symptoms.
- A multidisciplinary approach, involving surgeons, gastroenterologists, and other healthcare professionals, may be necessary to ensure optimal management of paraesophageal hernias 2, 3, 4, 6, 5.