Paraesophageal Hiatal Hernia

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Paraesophageal Hiatal Hernia
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• The esophageal hiatus is formed by the right crus
  and little or no left crus.
• The phrenoesophageal ligament, which holds the
  distal esophagus in place is formed by fusion by
  endothoracic and endoabdominal fascia at the
  esophageal hiatus.

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CLASSIFICATION

• There are 4 types of hiatal hernias.
• The sliding hernia or type I is the most common.

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Type I Hiatal Hernia

• The E-C junction moves through the hiatus to the
  visceral mediastinum.
• Increased abdominal pressure( pregnancy, obesity,
  or vomiting ) and vigorous esophageal contraction
  may contribute the development of the hernia.
• G-E reflux and esophagitis may occur due to loss
  of tone of the LES.

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Type II Hiatal Hernia

• It is uncommon.
• The phrenoesophageal membrane is not weakened
  diffusely but focally.
• The gastric fundus protrudes through the hiatus.

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• 52-1

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Type III Hiatal Hernia

• It is combined with type I and type II.
• It is frequently present when a type II hiatal
  hernia have been present for many years.

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Type IV Hiatal Hernia

• It refers hernia of organs other than the
  stomach.
• The T-colon and the omentum are the most common
  involved.
• The spleen and the small intestine may be
  involved.

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ANATOMY AND PHYSIOLOGY

• In a true paraesophageal hiatal hernia, the lower
  esophagus and the cardia remain fixed below the
  diaphragm in the posterior aspect of the
  diaphragmatic hiatus.
• The herniated organs are covered with a layer of
  the peritoneum that forms a true hernia sac,
  unlike the type I hiatal hernia, in which the
  stomach forms the posterior wall of hernia sac.

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ANATOMY AND PHYSIOLOGY

• Complications are bleeding, incarceration,
  volvulus, obstruction, strangulation and
  perforation.
• Gastritis and ulceration have been seen. The
  ulcer are the result of poor gastric emptying and
  torsion of the gastric wall.

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SYMPTOMS

• Many type I and type II hernia have few or no
  symptoms.
• Bleeding results from gastritis and ulcer can
  induce IDA, resulting in fatigue and exertional
  dyspnea.
• Postprandial discomfort may occur. The substernal
  fullness is often mistaken MI.

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SYMPTOMS

• In type II hernia, G-E reflux and true dysphagia
  is uncommon.
• If vovulus occurs, severe pain and pressure in
  the chest or epigastic region.
• Fever, hypovolemic shock will be present if
  volvulus progresses and strangulation occurs. In
  this situation, mortality rate is 50.

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DIAGNOSIS

• The diagnosis is suspected first on the CXR.
• The most common finding is retrocardiac bubble
  with or without air-fluid level.
• In a giant hiatal hernia, the herniated organ may
  be found in the right thoracic cavity.
• D.D mediastinal cyst or abscess, dilated
  obstructed esophagus, as end stage of achalasia.

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DIAGNOSIS

• The barium study of the UGI confirms the
  diagnosis.
• Endoscopy and esophageal function test can detect
  the function of LES.

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THERAPY

• There is no accepted medical treatment for hiatal
  hernia.
• Surgery is indicated to prevent complications.
• In type II hernia, if gastric volvulus or
  obstruction is present without toxic signs, NG
  decompression must be performed. The surgery is
  scheduled.

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Operative Approaches

• The operation or operative approach is
  controversial.
• The principles of operation is reduction of the
  hernia, resection of the hernia sac and closure
  of the defect.
• It is easy to do intrathoracic dissection via
  thoracotomy.
• However, transthoracic reduction may lead to
  volvulus of the gastric body.

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Operative Approaches

• Abdominal approach is also suggested.
• Additional procedures can be done, such as
  gastrotomy, which obviates the NG tube and
  decreases the risk of recurrent volvulus.
• Abdomional approach is difficult to do in type
  III hiatal hernia with G-E reflux and a
  foreshortened esophagus.
• Laparoscopic repair is also advocated.

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Should a Antireflux Procedure Be Induced?

• It is controversial.
• It is indicated in patients with esophagitis by
  symptoms and endoscopy, with a hypotensive LES( lt
  10 mmHg ) or positive 24-hour pH monitoring.

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Operative Technique Conventional Abdominal
Approach

• The author prefers abdominal approach via upper
  midline incision.
• In type II hernia, the E-C junction is still in
  the abdomen, bounded posteriorly with a fibrous
  band. It is careful not to take down the
  attachment.
• Dissection is done on the lower 4 to 8 cm of the
  esophagus.
• The repair is done with nonabsorbable O sutures.
  

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Operative Technique Conventional Abdominal
Approach

• Antireflux procedure is done when significant
  reflux esophagitis is present.
• A loose Nissen fundoplication is suggested by
  authors.
• If no fundoplication is performed then the
  stomach can be fixed by two methods Hill suture
  plication and Stamm gastrostomy.

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Operative Technique Conventional Abdominal
Approach

• Hill suture plication 3 interrupted
  nonabsorbable sutures between lesser curve of the
  stomach and preaortic fascia
• Stamm gastrostomy 2 functions
• 1. It eliminates the need of NG tube.
• 2. It fixes the stomach to the abdominal wall
• and to prevent volvulus.

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• 52-5

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Operative Technique Laparoscopic Approach
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• 52-6

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Operative Morbidity and Mortality

• The operative mortality is less than 0.5.
• If gasric volvulus occurs, the operative
  mortality is up to 14.
• Pulmonary complication may be seen in patients
  with aspiration resulting from volvulus or
  obstruction.
• Complication of gastric stasis may result from
  edema of the released gastric segment.

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Operative Morbidity and Mortality

• Other complications include gastric perforation,
  gastric bleeding, slipped Nissen fundoplication,
  small bowel obstruction and atelectasis.

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RESULTS

• Long-term results are excellent.
• Simultaneous antireflux procedure is ineffective
  prophylaxis against recurrent herniation
  resultant G-E reflux.
• The long-term result after laparoscopic repair is
  unknown.

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Thank You!