What are the treatment guidelines for large paraesophageal (hiatal) hernias?

Treatment Guidelines for Large Paraesophageal Hernia

Surgical repair is the recommended treatment for large paraesophageal hernias, with laparoscopic approach being the preferred method due to lower complication rates, shorter hospital stays, and faster recovery compared to open surgical approaches. 1, 2

Diagnostic Evaluation

• CT scanning is the most useful diagnostic method to detect complications such as bowel strangulation, with reduced wall enhancement being the most significant independent predictor (56% sensitivity and 94% specificity) 3
• Elevated white blood cell count can be moderately predictive of complications in patients with incarcerated hernias 3
• Water-soluble contrast swallow may be performed after repair to screen for perforation, though it is not essential 3

Surgical Approach

Laparoscopic Repair

• Laparoscopic repair should be the first-line approach for paraesophageal hernias, with success rates of up to 97% reported in experienced centers 2
• Key principles of repair include:
  • Reduction of the hernia 1
  • Excision of the hernia sac 1, 4
  • Crural approximation 1, 4
  • Fundoplication to "pexy" the stomach within the abdomen and control postoperative reflux 1

Type of Fundoplication

• Nissen fundoplication is commonly performed (complete 360° wrap) 1, 2
• Consider partial fundoplication (Toupet or Dor) in patients with esophageal hypomotility or impaired peristaltic reserve to reduce risk of postoperative dysphagia 3, 1
• Type of fundoplication may be tailored based on preoperative manometry findings 3

Considerations for Complex Cases

• Conversion to open repair may be necessary in approximately 3-10% of cases due to:

  • Iatrogenic esophageal injury 1
  • Difficult hernia sac dissection 1
  • Large hernia size or significant anatomic distortion 5

• For patients with gastroduodenal motility disorders, gastric outlet stenosis, or high risk of aspiration, consider placement of a feeding jejunostomy tube 3

Postoperative Management

• Proton pump inhibitor (PPI) therapy should be offered after repair to:

  • Reduce risk of reflux symptoms (which occur in 10-40% of patients) 3
  • Promote healing and prevent recurrence 3

• Provide patients with contact information for the on-call team in case they experience chest pain, breathlessness, or become unwell 3

• Monitor for potential complications:

  • Perforation (suspect when patients develop persistent pain, breathlessness, fever, or tachycardia) 3
  • Pneumothorax 2
  • Recurrent herniation (reported in approximately 6-9% of cases) 4, 2

Special Considerations

• Elderly patients with significant comorbidities may particularly benefit from the laparoscopic approach due to lower morbidity and faster recovery 4, 2

• Patients with symptoms of gastroesophageal reflux disease (GORD) should receive PPI therapy as this has been shown to reduce the need for subsequent interventions 3

• For obese patients with proven GERD, Roux-en-Y gastric bypass may be considered as an effective primary anti-reflux intervention, while sleeve gastrectomy has potential to worsen GERD 3

Common Pitfalls and Caveats

• Failure to excise the hernia sac completely may increase recurrence risk 4
• Inadequate crural repair can lead to early recurrence 4
• Overlooking esophageal shortening may result in increased tension on the repair 5
• Performing gastropexy without fundoplication may not adequately control reflux symptoms 1, 4
• Delayed recognition of intraoperative perforation can lead to significant morbidity and mortality 5, 1