What is the evaluation and management of a paraesophageal hernia?

Paraesophageal Hernia Evaluation and Management

CT scan with IV contrast is the recommended imaging modality for paraesophageal hernia evaluation, followed by surgical repair for symptomatic patients, preferably using a laparoscopic approach with mesh reinforcement for defects larger than 5 cm. 1

Diagnostic Evaluation

Initial Imaging

• First-line imaging: While ultrasound is generally recommended for abdominal hernias, for paraesophageal hernias specifically:
  • Double-contrast upper GI series (barium esophagram) is most effective for hiatal/paraesophageal hernias, providing both anatomic and functional information 1
  • CT scan with IV contrast is recommended for suspected diaphragmatic hernias, offering superior visualization of the hernia contents and potential complications 1

Advanced Imaging

• CT findings indicative of paraesophageal hernia:
  • Diaphragmatic discontinuity
  • "Dangling diaphragm" sign (free edge of ruptured diaphragm curling toward abdomen)
  • "Dependent viscera" sign (no space between herniated organs and chest wall)
  • "Collar sign" (constriction of herniating organ at rupture level) 2
  • CT can also evaluate for complications like ischemia (wall thickening, lack of enhancement, pneumatosis) 2

Additional Diagnostic Tests

• High-resolution manometry: Useful for evaluating associated motility disorders, showing a characteristic "double high pressure zone" pattern 1
• pH studies: Important when GERD symptoms are present to guide decision-making about antireflux procedures 2

Classification

Paraesophageal hernias are classified as Type II-IV hiatal hernias:

• Type II: True paraesophageal hernia (gastric fundus herniates while GE junction remains in normal position)
• Type III: Combined sliding and paraesophageal hernia (GE junction and fundus both herniate)
• Type IV: Large diaphragmatic defect allowing herniation of additional viscera (stomach, colon, spleen) 2

Management Approach

Indications for Surgery

• Surgery is recommended for all symptomatic paraesophageal hernias due to risk of serious complications including obstruction, incarceration, strangulation, and perforation 3
• For asymptomatic or minimally symptomatic patients, a watchful waiting approach may be reasonable, as elective repair benefits fewer than one in five patients 4

Surgical Approach

• Laparoscopic repair is the preferred approach for stable patients with paraesophageal hernias 2, 3
• Key surgical principles:
  1. Reduction of hernia contents
  2. Removal of the hernia sac
  3. Closure of the hiatal defect
  4. Addition of an antireflux procedure 5, 6

Mesh Reinforcement

• Mesh use is recommended for hiatal defects larger than 5 cm that cannot be closed with direct suture 2, 3
• Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher resistance to infections, and lower risk of displacement 2

Antireflux Procedure

• An antireflux procedure (typically Nissen fundoplication) is recommended during paraesophageal hernia repair due to high rates of postoperative reflux 6
• The type of fundoplication should be tailored to the patient's esophageal motility 1

Postoperative Management

• PPI therapy: Consider continuing PPI therapy after repair, particularly in patients with pre-existing GERD or Barrett's esophagus 1
• Lifestyle modifications: Recommend avoiding meals within 3 hours of bedtime, elevating head of bed, and weight management 1

Follow-up

• Regular surveillance is recommended to detect recurrence, which can occur in up to 42% of cases after primary repair without mesh reinforcement 2
• For patients with associated Barrett's esophagus, follow surveillance protocols with endoscopy every 3-5 years for non-dysplastic disease 1

Complications to Monitor

• Recurrence (most common complication)
• Dysphagia (particularly after fundoplication)
• Continued reflux symptoms
• Mesh-related complications (erosion, infection)

The laparoscopic approach with mesh reinforcement and fundoplication represents the current standard of care for symptomatic paraesophageal hernias, offering excellent visualization of the hiatus with significantly less physiologic insult to patients compared to open approaches.