Hiatus Hernia

A hiatus hernia is herniation of abdominal structures through the oesophageal hiatus.

Four anatomical types are recognised:

• Type I: sliding hernia, with proximal migration of the gastroesophageal junction.
• Type II: paraoesophageal hernia, with fundus herniating beside the oesophagus while the gastroesophageal junction remains below the diaphragm.
• Type III: mixed hernia, with both gastroesophageal junction and stomach above the diaphragm.
• Type IV: large defect containing stomach plus another abdominal organ.

Type I disease primarily causes reflux. Types II to IV create additional mechanical risks including obstruction, gastric volvulus, bleeding, aspiration and strangulation.

Sliding hernias commonly present with heartburn and regurgitation.

Large hernias may produce early satiety, postprandial chest or epigastric discomfort, dysphagia, regurgitation, dyspnoea or recurrent aspiration.

Chronic mucosal trauma at the diaphragmatic impression can produce Cameron erosions with occult blood loss and iron deficiency anaemia.

Acute severe epigastric or chest pain with persistent retching, inability to tolerate intake or inability to pass a nasogastric tube should raise concern for gastric volvulus or obstruction.

Upper gastrointestinal endoscopy: evaluates reflux injury, mucosal disease and the relationship of the gastroesophageal junction to the diaphragm.

Contrast swallow: defines hernia anatomy, oesophageal emptying, gastric rotation and the position of the gastroesophageal junction.

CT chest and upper abdomen: useful for large, complicated or acutely symptomatic hernias and identifies volvulus, obstruction or compromised stomach.

Manometry and reflux monitoring are obtained before elective antireflux reconstruction when clinically appropriate.

A small sliding hernia without clinically significant reflux does not require repair simply because it is present.

Treat reflux symptoms medically initially.

Surgery is appropriate when there is objectively significant reflux requiring operative treatment, persistent mechanical symptoms, progressive dysphagia, recurrent aspiration, bleeding related to the hernia, obstruction, volvulus or threatened gastric viability.

Repair consists of:

• Reduction of the herniated stomach and contents.
• Dissection of the hernia sac from the mediastinum.
• Adequate mediastinal oesophageal mobilisation.
• Restoration of approximately 2 to 3 cm of tension free intra abdominal oesophagus where achievable.
• Crural closure without excessive tension.
• Antireflux reconstruction in most elective type II, III and IV repairs.

Routine permanent mesh reinforcement of every hiatus repair is not supported by sufficiently consistent evidence. Use selectively for defects where primary closure is difficult or recurrence risk is particularly high.

A genuinely shortened oesophagus that cannot remain adequately below the diaphragm despite extensive mediastinal mobilisation may require a lengthening procedure such as Collis gastroplasty.

Acute volvulus, gastric ischaemia, perforation or uncontrolled obstruction requires urgent reduction and repair.