What is the treatment for hiatal hernia?

Treatment for Hiatal Hernia

Surgery is the definitive treatment for symptomatic or complicated hiatal hernias, with laparoscopic repair being the preferred approach in stable patients. 1

Initial Management Strategy

Asymptomatic Hiatal Hernias

• Watchful waiting is appropriate, as asymptomatic hiatal and paraesophageal hernias become symptomatic at a rate of only 1% per year 2
• Medical management with proton pump inhibitors (omeprazole 20 mg once daily) can control reflux symptoms in sliding hernias 3
• H2 blockers (ranitidine) are an alternative for symptom control 4

Symptomatic Hernias Requiring Surgery

• Surgical repair is recommended for all symptomatic hiatal hernias and those with confirmed reflux disease 1, 2
• Surgery becomes necessary when patients experience dysphagia, severe esophagitis, anemia, or respiratory/cardiac complications 5

Surgical Approach Selection

Stable Patients

• Laparoscopic approach is strongly recommended as the gold standard, offering improved outcomes with lower morbidity and shorter hospital stays 1, 2
• Minimally invasive surgery has an excellent safety profile with reported in-hospital mortality of 0.14% 1

Unstable Patients

• Laparotomy approach is indicated in hemodynamically unstable patients or those with severe complications 1
• Damage Control Surgery should be considered in patients with intraoperative instability, hypothermia, coagulopathy, or significant acidosis 1

Key Operative Steps

Essential Technical Components

• Complete reduction and excision of the hernia sac from the mediastinum 2, 6
• Achieve 3 cm of intra-abdominal esophageal length to prevent recurrence 2
• Primary crural closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers 1
• Anti-reflux procedure (fundoplication) should be performed in conjunction with hernia repair 2, 6

Mesh Reinforcement Considerations

• Mesh use is indicated for defects that cannot be closed with direct suture (>3 cm) or when primary repair would create excessive tension 1
• For defects larger than 8 cm or area >20 cm², mesh interposition is recommended 1
• Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher infection resistance, and lower displacement risk 1
• Mesh should overlap defect edges by 1.5-2.5 cm 1
• Avoid tackers near the pericardium due to risk of cardiac complications 1

Fundoplication Selection

Standard Approach

• Nissen fundoplication (360° wrap) remains the gold standard for durable GERD symptom relief 7
• A short, floppy Nissen technique is preferred in most cases 5

Modified Approach for Specific Patients

• Partial fundoplication (Toupet) is preferred in patients with esophageal hypomotility or impaired peristaltic reserve to reduce postoperative dysphagia risk 7

Special Population: Obese Patients

• Roux-en-Y gastric bypass is the preferred primary anti-reflux intervention in obese patients with hiatal hernia 7

Alternative Procedures for High-Risk Patients

Non-Surgical Candidates

• Percutaneous endoscopic gastrostomy (PEG) or gastrostomy is suggested for high-risk elderly patients unsuitable for definitive surgical repair 1
• These procedures provide anterior stomach fixation to the abdominal wall, relieve symptoms, prevent recurrence, and have very low morbidity 1
• Combined PEG/laparoscopy successfully stops progression of complications like gastric ischemia 1

Preoperative Assessment Requirements

Mandatory Workup

• High-resolution manometry to assess esophageal peristaltic function and exclude achalasia 7
• Complete endoscopic evaluation to document severity of esophagitis 7
• Confirmation of pathologic GERD before proceeding with invasive anti-reflux procedures 7
• CT scan is the gold standard for diagnosis, with sensitivity 14-82% and specificity 87% 1

Important Caveats

Anti-Reflux Surgery Timing

• Preemptive anti-reflux surgery is NOT recommended in emergency or complicated hernia settings 1
• Anti-reflux procedures should only be performed in patients with documented history of gastroesophageal reflux requiring repair of large defects 1

Recurrence Prevention

• Primary repair alone has a very high recurrence rate of 42% 1
• Mesh reinforcement significantly reduces recurrence in larger defects 1

Right-Sided Hernias

• Due to liver presence, right diaphragmatic hernias may require a combined or thoracic approach 1

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