Management of Complicated and Strangulated Hiatal Hernias

Abstract

Large, complicated hiatal hernias are relatively rare, typically affecting the elderly. Type II–IV hiatal hernias are also known as paraesophageal hernias, and the most prevalent is a type III hernia where the gastroesophageal junction migrates cephalad into the chest, frequently accompanied by a portion of the stomach adjacent to the esophagus, as a consequence of laxity in the phrenoesophageal attachments. Approximately half of all paraesophageal hernias are symptomatic, and most commonly, symptoms in the acute presentation are related to volvulus and obstruction and constitute nausea, postprandial chest or epigastric pain, and bloating. Other acute manifestations of paraesophageal hernia include strangulation, perforation, and bleeding. Diagnosis primarily relies on abdominal computed tomography and upper gastrointestinal series. The risk of developing acute gastric volvulus requiring emergency surgery is estimated at less than 2 % per year. Mortality following emergency surgery has historically been reported to be as high as 56 %, though currently in the laparoscopic era, it has decreased significantly to a rate of 5–20 %. All symptomatic paraesophageal hernias should be repaired, in accordance with the guidelines, and the standard approach is laparoscopic even in urgent cases. The principles of laparoscopic repair of large paraesophageal hernias in order to minimize recurrence are (1) reduction of the hernia with at least 2–3 cm of intra-abdominal esophageal length, (2) complete excision of the hernia sac, and (3) tension-free closure of the hiatus. Fixation of the stomach within the abdomen is traditionally performed via fundoplication, but gastropexy or gastrostomy tube placement is acceptable in certain instances.