From the Guidelines
Surgical repair is the recommended treatment for patients with paraesophageal hernia, particularly for symptomatic cases or those with large hernias, due to the risk of serious complications like strangulation, obstruction, or volvulus. The decision to operate should be based on symptom severity and patient factors, including the presence of gastroesophageal reflux, the size of the hernia, and the patient's overall health status 1. For asymptomatic patients with small hernias, watchful waiting with lifestyle modifications may be appropriate, including weight loss, avoiding large meals, elevating the head of the bed, and using acid-suppressing medications like proton pump inhibitors (such as omeprazole 20-40mg daily or pantoprazole 40mg daily).
The preferred surgical approach is laparoscopic repair, which typically involves hernia reduction, excision of the hernia sac, crural closure, and often a fundoplication procedure (usually Nissen or Toupet) to prevent reflux 1. Mesh reinforcement may be used in selected cases with large hiatal defects to reduce recurrence rates, with the mesh overlapping the defect edge by 1.5–2.5 cm 1. The choice of surgical approach, including the use of a minimally invasive abdominal approach or a thoracic approach, depends on the surgeon's preferences and skills, as well as the patient's condition and local resources 1.
Key considerations in the surgical management of paraesophageal hernia include:
- The need for fundoplication to prevent gastroesophageal reflux, particularly in patients with a history of reflux or large hiatal defects 1
- The use of mesh reinforcement to reduce recurrence rates in patients with large hiatal defects 1
- The choice of surgical approach, including laparoscopic or open repair, and the use of a minimally invasive abdominal approach or a thoracic approach 1
- The importance of individualizing treatment based on patient factors, including symptom severity, overall health status, and the presence of comorbidities.
From the Research
Treatment Options for Paraesophageal Hernia
The recommended treatment for a patient with a paraesophageal hernia is surgical repair, as it can help prevent complications such as obstruction, incarceration, strangulation, or perforation 2. The goal of surgery is to reduce the hernia, repair the hiatal defect, and prevent recurrence.
Surgical Approaches
There are different surgical approaches to repair a paraesophageal hernia, including:
- Laparoscopic repair, which is a minimally invasive approach that can be used to repair the hernia and reduce the risk of complications 2, 3, 4
- Open repair, which may be necessary in some cases, such as large hernias or those with significant complications 4
- The use of mesh to reinforce the hiatal repair and prevent recurrence, although the use of mesh is still a topic of debate 2, 3
Key Considerations
When repairing a paraesophageal hernia, several key considerations must be taken into account, including:
- The size and location of the hernia
- The presence of any complications, such as obstruction or strangulation
- The patient's overall health and medical history
- The surgical approach and technique used, including the use of mesh or fundoplication 5, 6, 3
Postoperative Care
After surgery, patients with a paraesophageal hernia require close monitoring and follow-up care to prevent complications and promote healing. This may include:
- Monitoring for signs of recurrence or complications, such as dysphagia or reflux symptoms 3
- Follow-up endoscopy or radiographic swallow studies to assess the repair and detect any potential problems 3, 4
- Management of any postoperative complications, such as leaks or perforations, which require early identification and expeditious intervention 5