Skip to main content

Hiatal hernias

Surgical and Radiologic Anatomy volume 34, pages 291–299 (2012)Cite this article

Abstract

Esophageal hiatal hernias have been reported to affect anywhere from 10 to 50% of the population. Hiatal hernias are characterized by a protrusion of the stomach into the thoracic cavity through a widening of the right crus of the diaphragm. There are four types of esophageal hiatal hernias: sliding (type I), paraesophageal (type II), and combined (type III), which include elements of types I and II, and giant paraesophageal (type IV). Each type may present with different symptoms and complications. The potential severity of symptoms necessitates proper and prompt diagnosis. Diagnosis is established with the use of barium swallow on chest radiographs. Treatment for sliding hernias involves laparoscopic fundoplication. The aim of our paper is to review the extensive literature regarding hiatal hernias in an effort to enhance awareness and diagnosis of this pathology.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Al-Assiri A, Wiseman N, Bunge M (2005) Prenatal diagnosis of intrathoracic stomach gastric herniation. J Pediatr Surg 40:E15–E17

    Article  PubMed  Google Scholar 

  2. Allison PR (1951) Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 92:419–431

    PubMed  CAS  Google Scholar 

  3. Alrabeeah A, Giacomantonio M, Gillis DA (1988) Paraesophageal hernia after Nissen fundoplication: a real complication in pediatric patients. J Pediatr Surg 23:766–768

    Article  PubMed  CAS  Google Scholar 

  4. Al-Salem AH (2000) Intrathoracic gastric volvulus in infancy. Pediatr Radiol 12:842–845

    Article  Google Scholar 

  5. Altorki NK, Yankelevitz D, Skinner DB (1998) Massive hiatal hernias: the anatomic basis of repair. J Thorac Cardiovasc Surg 115:828–835

    Article  PubMed  CAS  Google Scholar 

  6. Apaydin N, Uz A, Elhan A, Loukas M, Tubbs RS (2008) Does an anatomical sphincter exist in the distal esophagus? Surg Radiol Anat 30:11–16

    Article  PubMed  Google Scholar 

  7. Apaydin N, Uz A, Evirgen O, Loukas M, Tubbs RS, Elhan A (2008) The phrenico-esophageal ligament: an anatomical study. Surg Radiol Anat 30:29–36

    Article  PubMed  Google Scholar 

  8. Awais O, Luketich JD (2009) Management of giant paraesophageal hernia. Minerva Chir 64:159–168

    PubMed  CAS  Google Scholar 

  9. Botha GS (1958) The gastro-oesophageal region in infants; observations on the anatomy, with special reference to the closing mechanism and partial thoracic stomach. Arch Dis Child 33:78–94

    Article  PubMed  CAS  Google Scholar 

  10. Brunicardi FC (2004) Schwartz’s principles of surgery, 8th edn. McGraw-Hill, New York, pp 859–862

    Google Scholar 

  11. Carlson MA, Richards CG, Frantzides CT (1999) Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig Surg 16:407–410

    Article  PubMed  CAS  Google Scholar 

  12. Catarci M, Gentileschi P, Papi C et al (2004) Evidence-based appraisal of antireflux fundoplication. Ann Surg 239:325–337

    Article  PubMed  Google Scholar 

  13. Chandrasekar S, Welch RJ, Watson H (2006) Congenital mixed hiatus hernia in a neonate. Arch Dis Child Fetal Neonatal 91:F317

    Article  CAS  Google Scholar 

  14. Cuschieri A, Shimi S, Nathanson LK (1992) Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg 163:425–430

    Article  PubMed  CAS  Google Scholar 

  15. Davis SS Jr (2008) Current controversies in paraesophageal hernia repair. Surg Clin N Am 88:959–978

    Article  PubMed  Google Scholar 

  16. Del Genio G, Collard JM (2006) Acute complications of antireflux surgery. In: Ferguson MK, Fennerty MB (eds) Managing failed anti-reflux therapy. Springer, London, p 73

    Google Scholar 

  17. Delattre JF, Avisse C, Marcus C, Flament JB (2000) Functional anatomy of the gastroesophageal junction. Surg Clin N Am 80:241–260

    Article  PubMed  CAS  Google Scholar 

  18. Delattre JF, Palot JP, Ducasse A et al (1985) The crura of the diaphragm and the diaphragmatic passage. Applications to gastroesophageal reflux, its invention and treatment. Clin Anat 7:271–283

    Article  CAS  Google Scholar 

  19. Delmas A, Roux J (1938) Les gaines de l’oesophagediaphragmatique. Ann Anat Pathol 15:635–640

    Google Scholar 

  20. Draaisma WA, Gooszen HG, Tournoij E, Broeders IA (2005) Controversies in paraesophageal hernia repair: a review of literature. Surg Endosc 19:1300–1308

    Article  PubMed  CAS  Google Scholar 

  21. Drake RL, Vogl AW, Mitchell AWM (2010) Gray’s anatomy for students, 2nd edn. Churchill Livingstone, Philadelphia, p 352

    Google Scholar 

  22. Dunn DB, Quick G (1990) Incarcerated paraesophageal hernia. Am J Emerg Med 8:36–39

    Article  PubMed  CAS  Google Scholar 

  23. Fei L, Del Genio G, Rossetti G et al (2009) Hiatal hernia recurrence: surgical complication or disease? Electron microscope findings of the diaphragmatic pillars. J Gastrointest Surg 13:459–464

    Article  PubMed  Google Scholar 

  24. Fei L, Di Martino N, Amato G et al (1984) Effect of a slipped hiatal hernia on the activity of the lower esophageal sphincter and of the abdominal portion of the esophagus. A pH-manometric study. Minerva Med 75:2155–2160

    PubMed  CAS  Google Scholar 

  25. Ferri LE, Feldman LS, Stanbridge D et al (2005) Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach? Surg Endosc 19:4–8

    Article  PubMed  CAS  Google Scholar 

  26. Fischer JE, Bland KI, Calley MP et al (2007) Surgical anatomy of the diaphragm, mastery of surgery. Lippincott Williams & Wilkins, Philadelphia, pp 598–618

    Google Scholar 

  27. Fitzgibbons RJ, Greenburg AG, Nyhus LM (2001) Nyhus and Condon’s hernia, 5th edn. Lippincott Williams & Wilkins, Philadelphia, pp 480–505

    Google Scholar 

  28. Gonzalez de Santander R (1962) Contribucional estudo de la morfología desciurollo de la bursaomentalis en embriones humanos. An Desarrollo 10:269–298

    Google Scholar 

  29. Granderath FA, Schweiger UM, Pointner R (2007) Laparoscopic antireflux surgery: tailoring the hiatal closure to the size of hiatal surface area. Surg Endosc 21:542–548

    Article  PubMed  CAS  Google Scholar 

  30. Hashemi M, Peters JH, DeMeester TR et al (2000) Laparoscopic repair of large type III hiatal hernia: objective follow-up reveals high recurrence rate. J Am Coll Surg 190:553–560

    Article  PubMed  CAS  Google Scholar 

  31. Hayward J (1961) The phreno-esophageal ligament in hiatal hernia repair. Thorax 16:41–45

    Article  PubMed  CAS  Google Scholar 

  32. Hill LD, Aye RW, Ramel S (1990) Antireflux surgery: a surgeon’s look. Gastroenterol Clin North Am 19:745–775

    PubMed  CAS  Google Scholar 

  33. Hill LD, Tobias JA (1968) Paraesophageal hernia. Arch Surg 96:735–744

    Article  PubMed  CAS  Google Scholar 

  34. Hogan S, Pohi D, Bogetti D, Eubanks T, Pellegrini C (1999) Failed antireflux surgery. Arch Surg 134:809–817

    Article  Google Scholar 

  35. Horstmann R, Klotz A, Classen C et al (2004) Feasibility of surgical technique and evaluation of postoperative quality of life after laparoscopic treatment of intrathoracic stomach. Langenbecks Arch Surg 389:23–31

    Article  PubMed  CAS  Google Scholar 

  36. Imamoglu M, Cay A, Kosucu P et al (2005) Congenital paraesophageal hiatal hernia: pitfalls in the diagnosis and treatment. J Pediatr Surg 40:1128–1133

    Article  PubMed  Google Scholar 

  37. Jawad AJ, Al-Samarrai Al-MofadaS et al (1998) Congenital paraesophageal hiatal hernia in infancy. Pediatr Surg Int 13:91–94

    Article  PubMed  CAS  Google Scholar 

  38. Jetley NK, Al-Assiri AH, Al Awadi D (2009) Congenital para esophageal hernia: a 10 year experience from Saudi Arabia. Indian J Pediatr 76:489–493

    Article  PubMed  Google Scholar 

  39. Kahrilas PJ, Lin S, Chen J, Manka M (1999) The effect of hiatus hernia on gastro-esophageal junction pressure. Gut 44:476–484

    Article  PubMed  CAS  Google Scholar 

  40. Karpelowsky JS, Wieselthaler N, Rode H (2006) Primary paraesophageal hernia in children. J Pediatr Surg 41:1588–1593

    Article  PubMed  Google Scholar 

  41. Kramer P (1969) Does a sliding hiatus hernia constitute a distinct clinical entity? Gastroenterology 57:442–448

    PubMed  CAS  Google Scholar 

  42. Kuster GG, Gilroy S (1993) Laparoscopic technique for repair of paraesophageal hiatal hernias. J Laparoendosc Surg 3:331–338

    Article  PubMed  CAS  Google Scholar 

  43. Kwok H, Marriz Y, Al-Ali S, Windsor JA (1999) Phrenoesophageal ligament revisited. Clin Anat 12:164–170

    Article  PubMed  CAS  Google Scholar 

  44. Liebermann-Meffert D, MeVert LD, Allgöwer M et al (1979) Muscular equivalent of the lower esophageal sphincter. Gastroenterology 76:31–38

    PubMed  CAS  Google Scholar 

  45. Loukas M, Bellary SS, Tubbs SR et al (2011) Congenital diaphragmatic hernias: a review. Clin Anat (in press)

  46. Loukas M, Wartman CT, Tubbs RS et al (2008) Morphologic variation of the diaphragmatic crura: a correlation with pathologic processes of the esophageal hiatus? Folia Morphol 67:1–7

    Google Scholar 

  47. Maziak DE, Todd TR, Pearson FG (1998) Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 115:53–60

    Article  PubMed  CAS  Google Scholar 

  48. McVay CB (1984) Anson and McVay surgical anatomy, 6th edn. Saunders Co., Philadelphia, pp 357–369

    Google Scholar 

  49. Michelson E, Siegel CI (1964) The role of the phrenico-esophageal ligament in the lower esophageal sphincter. Surg Gynecol Obst 118:1291–1294

    CAS  Google Scholar 

  50. Nissen R (1956) Eineeinfache Operation zurBeeinflussung der Refluxo-esophagitis. Schwiez med Wochenschr 86:590–592

    CAS  Google Scholar 

  51. Ochsner JL, Hughes JP, Mills NL (1975) Repair of hiatal hernia: description and long-term results of a technique. Am Surg 41:629–631

    Google Scholar 

  52. Olsen AM, Holman CB, Harris LE (1960) Hiatal hernia in children: special reference to the short esophagus. Chest 38:495–506

    CAS  Google Scholar 

  53. Patel HJ, Tan BB, Yee J et al (2004) A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia. J Thorac Cardiovasc Surg 127:843–849

    Article  PubMed  Google Scholar 

  54. Pearson FG, Cooper JD, Ilves R et al (1983) Massive hiatal hernia with incarceration: a report of 53 cases. Ann Thorac Surg 35:45–51

    Article  PubMed  CAS  Google Scholar 

  55. Pellegrini CA (1998) Invited Commentary. In: Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg 186:428–432

    Article  Google Scholar 

  56. Salem AH (2000) Congenital paraesophageal hernia in infancy and childhood. Saudi Med J 21:164–167

    Google Scholar 

  57. Samujh R, Kumar D, Rao KL (2004) Paraesophageal hernia in the neonatal period: suspicion on chest X-ray. Indian Pediatr 41:189–191

    PubMed  Google Scholar 

  58. Schauer PR, Ikramuddin S, McLaughlin RH et al (1998) Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg 176:659–665

    Article  PubMed  CAS  Google Scholar 

  59. Schoenwolf GL, Bleyl SB, Brauer PR, Francist-West PH (2009) Development of the respiratory system and body cavities, Larsen’s human embryology. Elsevier, Philadelphia, pp 329–336

    Google Scholar 

  60. Sinaki B, Jayabose S, Sandoval C (2010) Iron-deficiency anemia associated with hiatal hernia: case reports and literature review. Clin Pediatr 49:984–985

    Article  Google Scholar 

  61. Skandalakis JE, Skandalakis PN, Skandalakis LJ (1995) Openings of the diaphragm, surgical anatomy and technique: a pocket manual. Springer, New York

    Google Scholar 

  62. Skandalakis JE (2005) Surgical anatomy, the embryologic and anatomic basis of modern medicine. Diaphragm, Chap 8. Paschalidis Medical Publication, Athens, pp 367–372

  63. Skandalkis JE, Gray SW (1972) The diaphragm in Gray and Skandalakis. In: Skandalkis JE, Gray SW (eds) Embryology for surgeons, the embryological basis for the treatment of congenital defects. WB Saunders, Philadelphia, pp 359–362

    Google Scholar 

  64. Skinner DB (1985) Hernias (hiatal, traumatic, and congenital). In: Berk JE (ed) Bockus gastroenterology, 4th edn. WB Saunders, Philadelphia, pp 705–747

    Google Scholar 

  65. Standring S, Ellis H, Healy JC et al (2005) Diaphragm and phrenic nerve. In: Gray’s anatomy, 39th edn. Churchill Livingstone, New York, pp 1081–1086

  66. Vas W, Malpani AR, Singer J et al (1989) Computed tomographic evaluation of paraesophageal hernia. Gastrointest Radiol 14:91–94

    Google Scholar 

  67. Walther B, DeMeester TR, Lafontaine E et al (1984) Effect of paraesophageal hernia on sphincter function and its implication on surgical therapy. Am J Surg 147:111–116

    Article  PubMed  CAS  Google Scholar 

  68. Watson DI, Davies N, Devitt PG, Jamieson GG (1999) Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias. Arch Surg 134:1069–1073

    Article  PubMed  CAS  Google Scholar 

  69. Williams PL, Bannister LH, Berry MM et al (1995) Alimentary system. In: Gray’s anatomy, 38th edn. Churchill Livingstone, Edinburgh, pp 1751–1753

  70. Wu JS, Dunnegan DL, Soper NJ (1999) Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc 13:497–502

    Article  PubMed  CAS  Google Scholar 

  71. Yadav K, Myers NA (1997) Paraesophageal hernia in the neonatalperiod-another differential diagnosis of esophageal atresia. Pediatr Surg Int 12:420–421

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Mohammadali M. Shoja, University of Alabama at Birmingham, Division of Neurosurgery, Birmingham, AL, USA for his valuable contribution to this work.

Conflict of interest

The paper is not under consideration elsewhere. All authors have read and approved the manuscript. All authors declare that there are no financial associations and no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Anatomical Sciences, School of Medicine, St George’s University, Grenada, West Indies

    Chase Dean, Denzil Etienne & Marios Loukas

  2. Department of Radiology, Boston University, Boston, MA, USA

    Bianca Carpentier

  3. Department of Anatomy, Varmia and Mazuria Medical School, Olsztyn, Poland

    Jerzy Gielecki & Marios Loukas

  4. Pediatric Neurosurgery, Children’s Hospital, Birmingham, AL, USA

    R. Shane Tubbs

Authors
  1. Chase Dean
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Denzil Etienne
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bianca Carpentier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jerzy Gielecki
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. R. Shane Tubbs
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Marios Loukas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Marios Loukas.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Dean, C., Etienne, D., Carpentier, B. et al. Hiatal hernias. Surg Radiol Anat 34, 291–299 (2012). https://doi.org/10.1007/s00276-011-0904-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00276-011-0904-9

Keywords

  • Fundoplication
  • Phrenico-esophageal ligament
  • Hiatus