What are the treatment options for hiatal hernia?

Hiatal Hernia Treatment

For symptomatic hiatal hernias or those with confirmed gastroesophageal reflux disease (GERD), laparoscopic surgical repair is the definitive treatment, while asymptomatic hernias can be managed with watchful waiting as they become symptomatic at only 1% per year. 1

Initial Assessment and Conservative Management

Medical Therapy for Type I (Sliding) Hernias

• Proton pump inhibitors (PPIs) form the cornerstone of medical management, with omeprazole 20 mg once daily for up to 4 weeks for symptomatic GERD, or 20 mg once daily for 4-8 weeks for erosive esophagitis 2
• Optimize lifestyle modifications including dietary sodium restriction, weight management, and positional changes 3
• Add adjunctive therapy with H2-receptor antagonists, alginate-containing antacids, baclofen, or prokinetics if gastroparesis coexists 3
• Medical therapy alone is appropriate only for Type I sliding hernias without complications or refractory symptoms 3, 4

Watchful Waiting Strategy

• Asymptomatic hiatal hernias and paraesophageal hernias require only observation, as the risk of becoming symptomatic is 1% annually 1
• Monitor for development of symptoms including heartburn, regurgitation, dysphagia, chest pain, or respiratory symptoms 5

Indications for Surgical Intervention

Absolute Indications

• Failure of optimized medical therapy (lifestyle modifications, maximal PPI dosing, and adjunctive medications) 3, 4
• Confirmed pathologic GERD with inadequate response to medical management 4
• Severe GERD requiring long-term treatment 3
• Complicated hernias with incarceration, volvulus, organ ischemia, or strangulation 3, 1

Preoperative Workup Requirements

• High-resolution esophageal manometry to assess peristaltic function and exclude achalasia 4
• 24-hour ambulatory pH-impedance monitoring to confirm pathologic reflux and determine mechanism of persistent symptoms 4
• Upper GI series (double-contrast esophagram) or endoscopy to define hernia size, type, and presence of complications 6

Surgical Approach and Technique

Laparoscopic vs. Open Surgery

• Laparoscopic repair is strongly preferred for stable patients, with significantly lower morbidity (5-6%) compared to open surgery (17-18%) 3, 7
• Laparotomy is reserved for hemodynamically unstable patients or those with acute complications 3

Essential Surgical Steps

The following components are critical for successful repair 1, 3:

1. Complete reduction of herniated contents and excision of hernia sac
2. Achievement of at least 3 cm intra-abdominal esophageal length 1
3. Crural closure with primary sutures (non-absorbable sutures mandatory to prevent recurrence) 3
4. Mesh reinforcement for defects >8 cm or area >20 cm², with mesh extending 1.5-2.5 cm beyond defect edges 3
5. Fundoplication (Nissen or Toupet technique) to prevent postoperative reflux 3, 7
6. Gastropexy in selected cases to prevent reherniation 7

Fundoplication Selection

• Nissen fundoplicature (360° wrap) is the most commonly performed technique 3
• Toupet fundoplicature (270° posterior wrap) may have lower recurrence rates in some studies and is preferred when esophageal dysmotility is present 3

Special Populations

Obese Patients with Hiatal Hernia

• Roux-en-Y gastric bypass is preferred over other bariatric procedures when addressing both obesity and hiatal hernia with GERD 4
• Avoid sleeve gastrectomy as it can worsen GERD symptoms 4

Patients Awaiting Liver Transplantation

• For cirrhotic patients with abdominal wall hernias and ascites, defer elective repair until during or after transplantation if transplant is imminent 6
• Control ascites with sodium restriction and diuretics before any elective hernia repair 6

Outcomes and Complications

Expected Outcomes

• Laparoscopic approach provides superior outcomes with lower morbidity compared to open surgery 3, 8
• Most patients achieve symptom resolution with appropriate surgical technique 1, 5

Common Complications

• Recurrence occurs in up to 25% of cases, often due to absorbable sutures, inadequate mesh fixation, increased intra-abdominal pressure, or technical errors 3, 7
• Postoperative complications include atelectasis, surgical site infection, bleeding, respiratory insufficiency, ileus, persistent reflux, chronic pain, and cardiac injury 3
• Avoid chest tube insertion; use tunneled indwelling catheters only in carefully selected patients 6

Prevention of Recurrence

• Use only non-absorbable sutures for crural closure 3
• Ensure adequate mesh fixation when indicated 3
• Control postoperative intra-abdominal pressure through weight management and treatment of conditions causing increased pressure 3
• Optimize nutrition postoperatively 6

Alternative Approaches for Non-Surgical Candidates

For patients who are not surgical candidates due to comorbidities or who refuse surgery:

• Continue optimized medical therapy with PPIs and adjunctive medications 3
• Consider gastropexy and gastrostomy tube placement as palliative alternatives when key surgical steps cannot be achieved 1
• Maintain close surveillance for development of complications requiring urgent intervention 1, 5