From the Guidelines
Laparoscopic repair is the recommended approach for managing large hiatal hernias in hemodynamically stable patients, as it reduces postoperative complications and facilitates early diagnosis of small diaphragmatic injuries 1. The management of large hiatal hernias involves a multidisciplinary approach, considering the patient's overall health, symptom severity, and potential complications.
Initial Management
Initial management should focus on conservative approaches, including:
- Dietary changes (small, frequent meals; avoiding fatty, spicy foods; limiting caffeine and alcohol)
- Weight loss if appropriate
- Elevating the head of the bed
- Avoiding lying down within 3 hours after eating Medication therapy often includes proton pump inhibitors (PPIs) such as omeprazole 20-40mg daily or pantoprazole 40mg daily for 8-12 weeks initially, then as needed for symptom control.
Surgical Intervention
Surgery is recommended for patients with:
- Persistent symptoms despite medical therapy
- Complications such as strangulation or obstruction
- Very large hernias (especially those containing more than 30% of the stomach)
- Paraesophageal hernias due to their risk of complications The standard surgical approach is laparoscopic hiatal hernia repair with fundoplication, which reduces the hernia and reinforces the lower esophageal sphincter.
Considerations
In critical patients, Damage Control Surgery (DCS) can be life-saving, and laparoscopic or thoracoscopic approaches have become the most used approaches to manage complicated diaphragmatic hernias, with minimally invasive surgery being safer and having shorter length of hospital stay and less morbidity compared with open surgery 1. Gastrostomy and PEG have added advantages for patients who have difficulties in oral intake, providing fixation of the anterior stomach to the abdominal wall and relieving symptoms, preventing recurrence, and stopping progression of complications 1.
From the Research
Management of Large Hiatal Hernias
The management of large hiatal hernias typically involves surgical repair, as conservative treatment is associated with a higher risk of complications such as stomach volvulus or severe bleeding 2.
Surgical Approach
- Minimally invasive surgery is the recommended approach for large hiatal hernia repair, with a low risk of postoperative complications 3.
- A complete hernia sac dissection should be considered, and extensive division of short gastric vessels cannot be recommended 3.
- Vagus nerve preservation is also recommended, and a dorso-ventral cruroplasty is suggested 3.
- Routine fundoplication should be considered to prevent postoperative gastroesophageal reflux, with posterior partial fundoplication being favored over other forms of fundoplication 3.
- Mesh augmentation is indicated in large hiatal hernias with paraesophageal involvement 3.
Outcomes and Complications
- Laparoscopic repair of large hiatal hernias is effective, with significant improvements in symptoms and quality of life 4, 5.
- The incidence of postoperative complications is relatively low, with rates ranging from 4.1% to 14.5% 4, 5, 6.
- Recurrence rates are also relatively low, with rates ranging from 4% to 5.8% 4, 5, 6.
- Patient satisfaction is high, with 85% to 93.8% of patients reporting improvement in their overall quality of life 4, 5.
Long-term Follow-up
- Long-term follow-up is essential to assess the efficacy of laparoscopic repair of large hiatal hernias, with a mean follow-up period of 3.2 years to 240 months 4, 5, 6.
- The use of mesh cruroplasty in large hiatal hernia repair leads to low recurrence rates, with no mesh-related complications noted on long-term follow-up 6.