Hiatal Hernia: Evaluation and Treatment
Initial Diagnostic Approach
For suspected hiatal hernia, obtain a fluoroscopic biphasic esophagram or upper GI series as the primary diagnostic test, which provides superior anatomic detail compared to endoscopy for hernia classification and surgical planning. 1
Imaging Strategy
Fluoroscopic studies (barium esophagram/upper GI series) are the gold standard for diagnosing hiatal hernias, determining size, and differentiating sliding from paraesophageal types—a critical distinction that determines surgical approach 1
The American College of Surgeons mandates that all patients considered for antireflux surgery require a barium esophagram 1
Double-contrast technique achieves 80% sensitivity for detecting reflux esophagitis and provides complete anatomic information including esophageal length, strictures, and hernia subtype 1
Upper endoscopy can complement imaging but is inferior for hernia classification 1
Key Diagnostic Information to Obtain
- Hernia type (I-IV classification), size, and presence of gastric volvulus 1, 2
- Esophageal length and presence of strictures 1
- Evidence of gastroesophageal reflux and esophagitis 1
- For large hernias, assess for herniation of other organs (colon, spleen) 2
Treatment Algorithm
Asymptomatic Hernias
- Watchful waiting is appropriate for asymptomatic hiatal hernias, as they become symptomatic requiring repair at only 1% per year 3
Symptomatic Non-Complicated Hernias
Surgery is indicated for symptomatic hiatal hernias or those with confirmed reflux disease, using a minimally invasive approach in stable patients. 1, 3
Surgical Approach Selection
Minimally invasive (laparoscopic) approach is preferred for stable patients with excellent safety profile and in-hospital mortality of only 0.14% 1
Laparoscopic repair shows lower morbidity (5-6%) compared to open approach (17-18%) 1
For right-sided hernias, liver presence may necessitate combined or thoracic approach 1
Essential Operative Steps
The following key steps must be included for optimal outcomes 3:
- Reduction and excision of hernia sac 3
- Achieve 3 cm of intraabdominal esophageal length 3
- Primary repair with non-absorbable sutures when possible 1
- Crural closure with mesh reinforcement for defects >8 cm or >20 cm² area 1, 3
- Anti-reflux procedure (fundoplication) 3
Common Pitfall: Mesh should overlap defect edges by 1.5-2.5 cm, and tackers must be avoided near the pericardium due to cardiac complication risk 1
Anti-Reflux Procedure Considerations
Fundoplication should be performed when there is history of gastroesophageal reflux, need to repair large defects, or paraesophageal/congenital hernias 1
Both Nissen and Toupet fundoplication are effective, though some data suggest lower recurrence with Toupet 1
Complicated Hernias (Emergency Setting)
Surgery is strongly recommended for complicated non-traumatic diaphragmatic hernias. 1
Approach Based on Stability
Unstable patients: Laparotomy approach is suggested 1
Stable patients: Minimally invasive approach is suggested despite complicated presentation 1
For critically unstable patients with severely injured organs, damage control surgery may be life-saving 1
Mesh Use in Emergency Setting
In clean-contaminated and contaminated repairs, biologic or biosynthetic meshes can be safely used 1
Surgeons are appropriately cautious about mesh in emergency settings due to infectious complication risk 1
Alternative Procedures for High-Risk Patients
For elderly or high-risk patients unsuitable for definitive repair, percutaneous endoscopic gastrostomy (PEG) with or without laparoscopy provides symptom relief, prevents recurrence progression, and has very low morbidity. 1
PEG provides anterior stomach fixation to abdominal wall and is well-tolerated in patients who cannot undergo major surgery 1
Gastropexy after reduction is successful for gastric volvulus cases 1
Type-Specific Considerations
Type I (Sliding) - 90% of Cases
- Usually managed medically unless symptoms are severe 2
- Requires surgery when symptomatic with confirmed reflux disease 3
Types II-IV (Paraesophageal Variants)
- Require surgical repair when symptomatic due to risk of incarceration and volvulus 2
- Type IV (giant hernias) may contain additional viscera requiring more extensive repair 2