Classification and Evaluation of Diaphragmatic Hernias

  • Adham R. Saad
  • Britney L. CoreyEmail author


Diaphragmatic hernias can be intimidating diagnoses for physicians who are unfamiliar with their workup and treatment. Often these hernias are incidental findings from diagnostic evaluations for reflux or ulcer disease, but they can also present in dire need of urgent surgery. Understanding the basics of evaluation and determining the urgency of treatment are essential in caring for this patient population. The large majority of these cases are not emergencies, and it is imperative for these patients to get a complete workup prior to surgical intervention. Through a discussion of the anatomy of the diaphragm and the esophageal hiatus, the pathophysiology of these hernias is more easily understood. In addition, the classification of these hernias and the appropriate diagnostic evaluation will be discussed. Our goal is to provide a fundamental guide for their classification and evaluation.


Diaphragmatic hernia Hiatal hernia Paraesophageal hernia Congenital diaphragmatic hernia Gastroesophageal junction Classification of hiatal hernia 


  1. 1.
    Bryant AS, Cerfolio RJ. Chapter 42. Diaphragmatic procedures. In: Souba WW, editor. ACS Surgery: Principles & Practice. New York: WebMD; 2007. p. 464.Google Scholar
  2. 2.
    Maish MS. The diaphragm. Surg Clin North Am. 2010;90(5):955–68.CrossRefGoogle Scholar
  3. 3.
    Kahrilas PJ, Kim HC, Pandolfino JE. Approaches to the diagnosis and grading of hiatal hernia. Best Pract Res Clin Gastroenterol. 2008;22(4):601–16.CrossRefGoogle Scholar
  4. 4.
    Kahrilas PJ, Lin S, Chen J, et al. The effect of hiatus hernia on the gastro-oesophageal junction pressure. Gut. 1999;44(4):476–82.CrossRefGoogle Scholar
  5. 5.
    Pouderoux P, Lin S, Kahrilas PJ. Timing, propagation, coordination, and effect of esophageal shortening during peristalsis. Gastroenterology. 1997;112(4):1147–54.CrossRefGoogle Scholar
  6. 6.
    Pandolfino JE, Zhang QG, Ghosh SK, et al. Transient lower esophageal sphincter relaxations and reflux: mechanistic analysis using concurrent fluoroscopy and high-resolution manometry. Gastroenterology. 2006;131(6):1725–33.CrossRefGoogle Scholar
  7. 7.
    Shi G, Pandolfino JE, Joehl RJ, et al. Distinct patterns of oesophageal shortening during primary peristalsis, secondary peristalsis, and transient lower oesophageal sphincter relaxation. Neurogastroenterology Motil. 2002;14(5):505–12.CrossRefGoogle Scholar
  8. 8.
    Pandolfino JE, El-Seraq HB, Zhang Q, et al. Obesity: a challenge to esophagogastric junction integrity. Gastroenterology. 2006;130(3):639–49.CrossRefGoogle Scholar
  9. 9.
    Menon S, Trudgill N. Risk factors in the aetiology of hiatus hernia: a meta-analysis. Eur J of Gastroenterol Hepatol. 2011;23(2):133–8.CrossRefGoogle Scholar
  10. 10.
    Perez AR, Moncure AC, Rattner DW. Obesity adversely affects the outcome of antireflux operations. Surg Endosc. 2001;15(9):986–9.CrossRefGoogle Scholar
  11. 11.
    Winslow ER, Frisella MM, Soper NJ, et al. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surg Endosc. 2003;17(12):2003–11.CrossRefGoogle Scholar
  12. 12.
    Luketina RR, Koch OO, Köhler G, et al. Obesity does not affect the outcome of laparoscopic antireflux surgery. Surg Endosc. 2015;29(6):1327–33.CrossRefGoogle Scholar
  13. 13.
    Oelschlager BK, Petersen RP, Brunt LM, et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes. J Gastrointest Surg. 2012;16:453–9.CrossRefGoogle Scholar
  14. 14.
    Zaman JA, Lidor AO. The optimal approach to symptomatic paraesophageal hernia repair: important technical considerations. Curr Gastroenterol Rep. 2016;18(10):53.CrossRefGoogle Scholar
  15. 15.
    Eren S, Ciris F. Diaphragmatic hernia: diagnostic approaches with review of the literature. Eur J Radiol. 2005;54(3):448–59.CrossRefGoogle Scholar
  16. 16.
    Schuchert MJ, Adusumilli PS, Cook CC, et al. The impact of scoliosis among patients with giant paraesophageal hernia. J Gastrointest Surg. 2011;15(1):23–8.CrossRefGoogle Scholar
  17. 17.
    Karpelowsky JS, Wieselthaler N, Rode H. Primary paraesophageal hernia in children. J Pediatr Surg. 2006;41(9):1588–93.CrossRefGoogle Scholar
  18. 18.
    Weber C, Davis CS, Shankaran V, et al. Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc. 2011;25(10):3149–53.CrossRefGoogle Scholar
  19. 19.
    Christensen J, Miftakhov R. Hiatus hernia: a review of evidence for its origin in esophageal longitudinal muscle dysfunction. Am J Med. 2000;108(Suppl 4a):3S–7S.CrossRefGoogle Scholar
  20. 20.
    Curci JA, Melman LM, Thompson RW, et al. Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia. J Am Coll Surg. 2008;207(2):191–6.CrossRefGoogle Scholar
  21. 21.
    Rosch R, Klinge U, Si Z, et al. A role for the collagen I/III and MMP-1/−13 genes in primary inguinal hernia. BMC Med Genet. 2002;3:2.CrossRefGoogle Scholar
  22. 22.
    Si Z, Bhardwai R, Rosch R, et al. Impaired balance of type I and type III procollagen mRNA in cultured fibroblasts of patients with incisional hernia. Surgery. 2002;131(3):324–31.CrossRefGoogle Scholar
  23. 23.
    Fei L, del Genio G, Rossetti G, et al. Hiatal hernia recurrence: surgical complication or disease? Electron microscope findings of the diaphragmatic pillars. J Gastrointest Surg. 2009;13(3):459–64.CrossRefGoogle Scholar
  24. 24.
    Pandolfino JE, Shi G, Trueworthy B, et al. Esophagogastric junction opening during relaxation distinguishes nonhernia reflux patients, hernia patients, and normal subjects. Gastroenterology. 2003;125(4):1018–24.CrossRefGoogle Scholar
  25. 25.
    Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g1654.CrossRefGoogle Scholar
  26. 26.
    Skinner DB. Chapter 53. Hernias. In: Berk JE, editor. Gastroenterology. Philadelphia: W.B. Saunders; 1985. p. 705.Google Scholar
  27. 27.
    Minneci PC, Deans KJ, Kim P, et al. Foramen of Morgagni hernia: changes in diagnosis and treatment. Ann Thorac Surg. 2004;77(6):1956–9.CrossRefGoogle Scholar
  28. 28.
    Nasr A, Fecteau A. Foramen of Morgagni hernia: presentation and treatment. Thorac Surg Clin. 2009;19(4):463–8.CrossRefGoogle Scholar
  29. 29.
    McHoney M. Congenital diaphragmatic hernia, management in newborn. Pediatr Surg Int. 2015;31(11):1005–13.CrossRefGoogle Scholar
  30. 30.
    Collet D, Luc G, Chiche L. Management of large Para-esophageal hiatal hernias. J Visc Surg. 2013;150(6):395–402.CrossRefGoogle Scholar
  31. 31.
    Jones MP, Sloan SS, Jovanovic B, et al. Impaired egress rather than increased access: an important independent predictor of erosive oesophagitis. Neurogastroenterol Motil. 2002;14(6):625–31.CrossRefGoogle Scholar
  32. 32.
    Khanna A, Finch G. Paraesophageal herniation: a review. Surgeon. 2011;9(2):104–11.CrossRefGoogle Scholar
  33. 33.
    Low DE, Simchuk EJ. Effect of paraesophageal hernia repair on pulmonary function. Ann Thorac Surg. 2002;74(2):333–7.CrossRefGoogle Scholar
  34. 34.
    Bawahab M, Mitchell P, Church N, et al. Management of acute paraesophageal hernia. Surg Endosc. 2009;23(2):255–9.CrossRefGoogle Scholar
  35. 35.
    Ott DJ, Gelfand DW, Chen YM, et al. Predictive relationship of hiatal hernia to reflux esophagitis. Gastrointest Radiol. 1985;10(4):317–20.CrossRefGoogle Scholar
  36. 36.
    Bytzer P. Information bias in endoscopic assessment. Am J Gastroenterol. 2007;102(8):1585–7.CrossRefGoogle Scholar

Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Minimally Invasive GI Surgery, Department of SurgeryUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Department of SurgeryUniversity of Alabama at Birmingham, Birmingham Veteran’s Affairs Medical CenterBirminghamUSA

Personalised recommendations