Overview
Definition:
Paraesophageal hernias are a type of diaphragmatic hernia where a portion of the stomach, and sometimes other abdominal organs like the colon or omentum, herniates through the esophageal hiatus into the mediastinum, with the gastroesophageal junction remaining in its normal anatomical position
Repair involves returning the herniated contents to the abdomen and reinforcing the hiatus, often with a fundoplication (full or partial) and gastropexy to prevent recurrence and gastric volvulus.
Epidemiology:
Paraesophageal hernias account for approximately 5-10% of all hiatal hernias
They are more common in older adults, particularly females, and are often associated with obesity and aging-related changes in the diaphragm.
Clinical Significance:
Paraesophageal hernias can lead to significant morbidity due to gastric volvulus, strangulation, perforation, or chronic symptoms such as dysphagia, regurgitation, chest pain, and anemia
Surgical repair is indicated for symptomatic patients and those at high risk of complications
Understanding the nuances of repair, including gastropexy, is crucial for successful surgical outcomes and preventing recurrence.
Indications For Surgery
Symptomatic Hernias:
Dysphagia
Chest pain mimicking angina
Recurrent nausea or vomiting
Postprandial fullness or early satiety
Hematemesis or melena due to mucosal erosion or ischemia.
Asymptomatic Large Hernias:
Hernias >50% of the stomach in the chest
Risk of gastric volvulus
Symptoms of respiratory compromise due to mediastinal mass effect
Patients who are candidates for other abdominal surgery where accessing the stomach is beneficial.
Acute Complications:
Gastric volvulus
Strangulation or incarceration
Perforation
Hemorrhage.
Preoperative Assessment
History And Physical:
Detailed history of symptoms, onset, duration, and aggravating/alleviating factors
Physical examination focusing on general condition, nutritional status, cardiopulmonary assessment, and abdominal findings.
Endoscopy:
Upper GI endoscopy to confirm the diagnosis, assess the size of the hernia, evaluate for esophagitis, Barrett's esophagus, ulcers, or malignancy, and visualize the gastroesophageal junction.
Imaging:
Barium swallow or esophagogram to delineate the size and extent of the hernia, gastric anatomy, and presence of volvulus
Chest X-ray may reveal a retrocardiac mass
CT scan of the chest and abdomen can provide detailed anatomical information and identify associated pathology.
Pulmonary Function Tests:
Important for assessing respiratory reserve, especially in patients with large hernias causing pulmonary symptoms or those undergoing thoracoscopic repair.
Cardiac Evaluation:
Essential due to potential for cardiac symptoms mimicking cardiac disease and increased risk in older patients.
Surgical Management
Approach:
Laparoscopic repair is the preferred approach due to faster recovery, reduced pain, and smaller incisions
Open repair (thoracotomy or laparotomy) may be necessary for complex cases, emergencies, or if laparoscopy is contraindicated.
Hiatal Hernia Repair:
Reduction of herniated contents
Careful dissection of the sac from mediastinal structures
Excision of the sac
Crural repair (closure of the diaphragmatic hiatus) to reduce the size of the opening, typically using sutures to approximate the cura
This is crucial to prevent recurrence.
Gastropexy:
Fixation of the stomach to the abdominal wall
Anterior gastropexy (e.g., Hill, Nissen variant, or modified Rossetti) involves suturing the anterior gastric wall to the crura or abdominal wall
Posterior gastropexy involves fixation to the posterior abdominal wall or peritoneum
The goal is to prevent recurrence of the hernia and gastric volvulus.
Fundoplication:
Often performed concurrently, especially in cases of associated reflux or to buttress the repair
A 270-degree (Belsey Mark IV) or 360-degree (Nissen) wrap may be performed
Choice depends on surgeon preference and intraoperative findings.
Postoperative Care
Diet:
Initially, clear liquids are initiated and gradually advanced to soft foods
Patients are instructed on small, frequent meals and avoiding gas-producing foods
Avoidance of carbonated beverages and straws for several weeks.
Pain Management:
Adequate analgesia is essential, typically with intravenous or oral opioids and NSAIDs
Patient-controlled analgesia (PCA) may be used postoperatively.
Ambulation:
Early ambulation is encouraged to prevent venous thromboembolism and promote lung expansion.
Monitoring:
Close monitoring for signs of bleeding, infection, leaks, dysphagia, or respiratory distress
Vital signs and urine output are carefully tracked.
Discharge Planning:
Patients are typically discharged within 1-3 days for laparoscopic repair
Follow-up appointments are scheduled to assess recovery and dietary progression.
Complications
Early Complications:
Bleeding
Infection
Injury to adjacent organs (spleen, esophagus, stomach, vagus nerve)
Pneumothorax (especially with thoracoscopic repair)
Gastric perforation
Esophageal injury
Diaphragmatic dehiscence.
Late Complications:
Hernia recurrence
Gastric stasis or outlet obstruction
Dysphagia
Reflux esophagitis
Gastric volvulus
Stomal stenosis
Dumping syndrome (rare).
Prevention Strategies:
Meticulous surgical technique, adequate hiatal closure, secure gastropexy, careful dissection, and appropriate patient selection
Postoperative dietary modifications and adherence to follow-up protocols are also important.
Prognosis
Factors Affecting Prognosis:
The success of repair depends on the size of the hernia, surgeon's experience, the chosen technique, and patient's adherence to postoperative instructions
Comorbidities also play a role.
Outcomes:
Successful repair leads to significant relief of symptoms and prevention of acute complications
Laparoscopic repair generally offers excellent outcomes with high success rates.
Follow Up:
Long-term follow-up is recommended, especially for patients with significant comorbidities or those who have undergone extensive repairs
Regular review to monitor for recurrence or late complications.
Key Points
Exam Focus:
Differentiate paraesophageal from other types of hiatal hernias
Understand indications for surgical repair, especially in asymptomatic patients at risk of complications
Recall the principles of hiatal closure, gastropexy, and the role of fundoplication
Recognize potential early and late complications.
Clinical Pearls:
For laparoscopic repair, creating a wide enough working space and meticulous dissection are key
Always perform adequate hiatal closure to prevent recurrence
Gastropexy is vital to prevent gastric volvulus
Consider concurrent anti-reflux procedure if indicated.
Common Mistakes:
Inadequate hiatal closure leading to recurrence
Overly tight closure causing dysphagia or gastric outlet obstruction
Failure to secure the stomach with gastropexy, leading to volvulus
Injury to adjacent organs during dissection.