What is the diagnosis and treatment for a hiatal hernia?

From the Guidelines

Hiatal hernias should be treated with lifestyle modifications and medications for mild cases, while surgery, specifically Nissen fundoplication, is recommended for large hernias or persistent symptoms despite medication. Treatment of hiatal hernias depends on the severity and symptoms of the condition. According to the study by Giuffrida et al. 1, the management of complicated diaphragmatic hernia, including hiatal hernias, requires a comprehensive approach. For mild cases, lifestyle modifications are recommended, including:

• Avoiding large meals
• Not lying down after eating
• Elevating the head of the bed 6-8 inches
• Maintaining a healthy weight
• Avoiding tight clothing around the waist
• Quitting smoking
• Limiting foods that trigger reflux, such as spicy, fatty, acidic foods, chocolate, caffeine, and alcohol.

Medications may also be prescribed, including:

• Antacids (Tums, Rolaids) for immediate relief
• H2 blockers (famotidine 20mg twice daily, ranitidine 150mg twice daily) to reduce acid production
• Proton pump inhibitors (omeprazole 20mg daily, esomeprazole 40mg daily) for more severe symptoms, as reported by 1. These medications should be taken 30-60 minutes before meals for optimal effect.

Surgery may be necessary for large hernias or persistent symptoms despite medication. The most common procedure is Nissen fundoplication, which wraps the upper part of the stomach around the lower esophagus to strengthen the barrier against acid reflux, as described in the study by Giuffrida et al. 1. This procedure has been shown to be effective in managing gastroesophageal reflux, with a reported incidence of up to 62% after repair of congenital diaphragmatic hernia 1. Factors affecting the surgical procedure selection include the history of gastroesophageal reflux, the need to repair a large defect, a paraesophageal hernia, or a congenital hernia, as noted in the study by Giuffrida et al. 1.

The classification of hiatal hernias into four main types, as described in the study by 1, is important for determining the appropriate treatment approach. Type I is a sliding hiatal hernia, Type II is a paraesophageal hiatal hernia, Type III is a combination of Type I and Type II, and Type IV is a significantly large diaphragmatic hernia that can accommodate the herniation of additional viscera.

In terms of surgical approach, a minimally invasive abdominal approach can be performed with an excellent safety profile and a reported overall in-hospital mortality rate of 0.14%, as reported by Giuffrida et al. 1. The use of mesh to overlap the defect edge by 1.5–2.5 cm is also recommended, with tackers or transfascial sutures used to fix the mesh in place, as described in the study by Giuffrida et al. 1.

Overall, the treatment of hiatal hernias requires a comprehensive approach that takes into account the severity and symptoms of the condition, as well as the classification of the hernia and the need for surgical intervention. Nissen fundoplication is the recommended surgical procedure for large hernias or persistent symptoms despite medication, as it has been shown to be effective in managing gastroesophageal reflux and strengthening the barrier against acid reflux.

From the Research

Diagnosis of Hiatal Hernia

• Hiatal hernia is commonly detected during endoscopic examinations and is associated with gastroesophageal reflux disease 2
• Two types of hiatal hernia have been described: sliding hernia and paraesophageal hernia (PEH), with sliding hernia being the most frequent and associated with reflux disease 3
• Symptoms of hiatal hernia are related to reflux disease, as well as intrathoracic compression symptoms due to the dislodgement of intrathoracic organs into the mediastinum 4

Treatment of Hiatal Hernia

• Surgical techniques for hiatal hernia repair include open surgery, various laparoscopic procedures, transoral incisionless fundoplication, and magnetic sphincter augmentation (MSA) 2
• Laparoscopic Nissen fundoplication is often considered the standard for treating gastroesophageal reflux disease-related hiatal hernia due to its effectiveness 2
• Other procedures, such as Toupet and Dor fundoplications, may be suited for patients with specific conditions, such as impaired esophageal motility 2
• Newer approaches, including the MSA system and mesh repair, focus on patient-specific treatments to achieve the best outcomes 2
• The primary aims of surgery are the repositioning of the herniated contents and a hiatoplasty, which includes a surgical narrowing of the esophageal hiatus by suture implantation 5
• Key operative steps include reduction and excision of hernia sac, 3 cm of intraabdominal esophageal length, crural closure with mesh reinforcement, and an anti-reflux procedure 6

Surgical Strategy

• The indications for surgical treatment of hiatus hernias differentiate between type I and types II, III, and IV hernias 5
• The indications for a type I hernia should include a proven reflux disease, but the indications for surgical treatment of types II, III, and IV hernias are mandatory due to the symptoms with problems in the passage of food and due to the sometimes very severe possible complications 5
• An adaptation to the specific needs situation of the patient and the expertise of the surgeon is essential 5
• A minimally invasive approach is safe and has improved outcomes 6