Hiatal Hernia: Update and Technical Aspects

Abstract Hiatal hernia is defined as the herniation of the stomach, possibly with other abdominal cavity elements, through the esophageal hiatus of the diaphragm. The most used classification describes four types of hernia: type I is the sliding hiatus hernia; type II the rolling hernia, where the gastric fundus herniate, while the gastroesophageal junction remains in the abdomen; type III the mixed hernia: with elements of both types I and II hernias; type IV is characterized by the presence of organs other than the stomach in the hernia sac. Types II–IV hernias as a group are referred to as paraesophageal hernias. Type I is the most common (95% of the cases), followed by type III, which comprises almost all paraesophageal hernias. Type II and IV are rare. Gastric volvulus is commonly associated with paraesophageal hiatal hernias. During sac reduction, the content is also retracted into the abdomen and the volvulus is automatically derotated. Natural history of hiatal hernias is not really known, but preliminary studies suggest that, like all other types of hernia, they tend to increase in size over time. The anatomic disruption of the gastroesophageal junction, due to hiatal hernia, leads to the disruption of natural anti-reflux mechanisms and hernia size is one of the main determinant of reflux severity [3]. Indeed, symptoms of hiatal hernia can be distinguished into GERD-related and Non-GERD-related. GERD symptoms are described in another chapter. Non-GERD symptoms include all those related to compression of mediastinal structures and to damage of herniated organs. A particular case is that of asymptomatic paraesophageal hernias. In those patients, prophylactic paraesophageal hernia repair is debated among experts. Although there is no consensus, most would agree that very old or debilitated patients should not undergo surgery, while younger and healthier patients, with a life expectancy of at least 10 years, should consider surgery to prevent both the risk of acute complications and potentially progressive symptoms.