Paraesophageal hernias, also known as Hiatal Hernias, are a relatively uncommon surgical problem. Since a large portion of these hernias occur in elderly people with multiple medical problems, repair of them has always been challenging. A recent publication has provided a current update for management of this surigical issue in 2011 (Kehdy, F. Invited Commentary: Current Managemen of Paraesophageal Hernia, The American Surgeon, Vol 77, No 12, p 1565, Dec. 2011).
There are four types of hiatal hernias. Type I Hiatal Hernias are the sliding type of hernia, are the most common, and are commonly managed with anti-secretory antacid medication. The surgical treatment of this disease, when refractory to medical management, is an antireflux procedure such as a Nissen fundoplication. Type II hiatal hernias (aka Rolling type) have a true defect in the hiatus of the diaphragm. These types of hernias have the stomach herniating into chest cavity. The GE junction (gastroesophageal junction is where the esophagus joins with the stomach in the abdomen) remains fixed to its normal anatomic position at the para-aortic fascia (connective tissue). Type III Hiatal Hernias have the GE junction and a portion of the stomach herniating up into the chest cavity. Type IV Hiatal Hernias is essentially a Type III Hiatal Hernia, but other abdominal organs are herniating into the chest as well (i.e. the small intestines, omentum or colon).
Paraesophageal Hiatal Hernias deserve repair, even in patients with mild or no symptoms. The reason for this is because the potential complications of leaving them untreated are potentially disastrous. Some surgeons have recently advocated a “watchful waiting” approach to dealing with older patients with hiatal hernias (i.e 65 years and older). Unfortunately, the data on this type of approach do not clearly support it.
There are many different ways of repairing hiatal hernias. At ROX Hernia center, a laparoscopic technique is preferred in patients who are acceptable candidates. The basic components involved in hiatal hernia repair include:
- Tension-free reduction of the stomach and esophagus into the abdominal cavity
- Excision of the hernia sac
- Repair (reapproximation) of the edges of the diaphragm muscle (the crura)
- Intra-abdominal anchoring of the stomach to decrease the risk of reherniation.