What are the treatment options for hiatal hernia?

Hiatal Hernia Treatment

For Type I sliding hiatal hernias without complications, start with optimized medical therapy (lifestyle modifications, maximal PPI dosing, and adjunctive medications), but proceed to laparoscopic surgical repair if medical management fails or if you're dealing with Type II-IV hernias, severe GERD, or any complications. 1

Initial Conservative Management (Type I Sliding Hernias Only)

Medical therapy is appropriate only for uncomplicated Type I sliding hernias (which represent 90% of all hiatal hernias) 1, 2. This approach includes:

• Lifestyle optimization: dietary sodium restriction, weight management, and positional changes 1
• Maximal PPI therapy as the foundation of medical management 1
• Adjunctive medications: H2-receptor antagonists, alginate-containing antacids, baclofen, or prokinetics if gastroparesis coexists 1

However, understand that asymptomatic hernias progress to symptomatic disease requiring repair at only 1% per year, so watchful waiting is reasonable for truly asymptomatic patients 3.

Mandatory Surgical Indications

Surgery is non-negotiable in these scenarios:

• Failure of optimized medical therapy (lifestyle modifications plus maximal PPI plus adjunctive medications) 1
• Confirmed pathologic GERD with inadequate response to medical management 1, 4
• Severe GERD requiring long-term treatment (such as LA Grade C esophagitis with persistent symptoms) 4
• Complicated hernias with incarceration, volvulus, organ ischemia, or strangulation—these require immediate surgical intervention 1
• Type II-IV paraesophageal hernias that are symptomatic 2, 3

Preoperative Workup (Required Before Surgery)

Before proceeding to surgery, complete this diagnostic algorithm:

• High-resolution esophageal manometry to assess peristaltic function and exclude achalasia (this determines whether you can perform a full Nissen vs. partial fundoplication) 1, 4
• 24-hour ambulatory pH-impedance monitoring to confirm pathologic reflux and determine the mechanism of persistent symptoms 1
• Upper GI series (double-contrast esophagram) or endoscopy to define hernia size, type, and presence of complications 1, 4
• Barium swallow specifically to identify strictures or short esophagus 4

The double-contrast upper GI series is particularly useful as it provides anatomic and functional information on esophageal length, strictures, presence of reflux, and reflux esophagitis 5.

Surgical Approach and Technique

Laparoscopic repair is strongly preferred for stable patients, with significantly lower morbidity (5-6%) compared to open surgery (17-18%) 1, 2. Reserve laparotomy only for hemodynamically unstable patients 2.

Critical Surgical Steps (All Must Be Performed):

1. Complete reduction of herniated contents and excision of hernia sac 1

2. Crural closure with non-absorbable sutures (absorbable sutures are a major cause of recurrence—never use them) 1, 2

3. Mesh reinforcement for defects >8 cm or area >20 cm², with mesh extending 1.5-2.5 cm beyond defect edges 1, 2

4. Achieve 3 cm of intra-abdominal esophageal length 3

5. Fundoplication (Nissen 360° or Toupet 270° technique) to prevent postoperative reflux 1, 4

Choosing Between Nissen vs. Toupet Fundoplication:

• Nissen fundoplication (360° wrap) is the gold standard with the most durable relief and lowest failure rate, but carries higher risk of postoperative dysphagia 4
• Toupet fundoplication (270° posterior wrap) has potentially lower dysphagia rates and some studies suggest lower recurrence rates 2, 4
• Base your choice on preoperative manometry results: if esophageal peristalsis is impaired, favor Toupet over Nissen 4

Special Populations

• Obese patients with GERD: Roux-en-Y gastric bypass is preferred over other bariatric procedures; avoid sleeve gastrectomy as it worsens GERD 1
• Cirrhotic patients with ascites: defer elective repair until during or after transplantation if transplant is imminent 1

Expected Complications and Recurrence Prevention

Recurrence occurs in up to 25% of cases 1. The primary causes are:

• Use of absorbable sutures (always use non-absorbable) 1, 2
• Inadequate mesh fixation when mesh is indicated 1, 2
• Increased intra-abdominal pressure (control through weight management and treatment of conditions causing increased pressure) 1
• Poor nutrition postoperatively 1

Other postoperative complications include atelectasis, surgical site infection, bleeding, respiratory insufficiency, ileus, persistent reflux, chronic pain, and cardiac injury 1, 2.

Alternative Approach for Non-Surgical Candidates

For patients who cannot undergo standard repair (severe comorbidities, inability to achieve key surgical steps), consider gastropexy and gastrostomy placement as an alternative palliative procedure 3.