Hiatal Hernias: Fix or Follow?
James A. Harris, M.D.
The increasing use of radiologic imaging has increased the frequency of detecting hiatal hernias. These hernias may cause symptoms such as dysphagia, heartburn, regurgitation and chest pain or they may be asymptomatic. Some require surgical repair and others can be followed. There are several types of hiatal hernias.
The decision to surgically repair a hiatal hernia depends on the presence of symptoms, the type of hernia and the condition of the patient. A Type I sliding hernia typically causes GERD symptoms. The most common indication to surgically repair this type of hernia is failure to adequately control GERD symptoms with medical treatment. Asymptomatic Type I hiatal hernias can be followed.
A Type II Paraesophageal hernia (PEH) has a more dangerous natural history. As the stomach migrates into the chest, it undergoes axial rotation. This significantly increases the risk of intrathoracic strangulation and gastric volvulus/necrosis, which has up to a 50% mortality. For this reason, the mere presence of a Type II PEH should require prompt surgical correction.
Axial Rotation of a Paraesophageal Hernia
Most large hiatal hernias are the Type III, Mixed/Combination type. The GE junction has migrated into the chest and the fundus has migrated further into the chest, coming to lie alongside the esophagus. The following may prompt one to choose surgical repair:
- Symptoms of dysphagia or postprandial fullness/pain
- GERD symptoms not well controlled
- A large paraesophageal component
- A young, medically fit patient
Repair of hiatal hernias involves mobilization of the stomach and esophagus and reduction back into the abdominal cavity. A 360 degree fundoplication (Nissen) is used to prevent GERD and to anchor the stomach in the abdomen. Laparoscopic techniques have dramatically decreased the morbidity of these procedures and have allowed many more patients to be candidates for surgery. Gastrointestinal, cardiac and pulmonary complications are reduced by the absence of an ileus, early ambulation, less pain, less fluid shifts, etc. There is a decrease in length of hospital stay and time to return to normal activity. |
Type I. Sliding hiatal hernia . 
Type II. Paraesophageal hernia . The GE junction remains at or near the diaphragm and the fundus of the stomach migrates into the chest alongside the esophagus . A pure paraesophageal hernia is uncommon. Typical symptoms are dysphagia and postprandial chest pain, but GERD symptoms can occur as well. 
Type III. Mixed Hiatal Hernia. This is a combination of Types I and II. The GE junction is above the diaphragm and the fundus of the stomach migrates up alongside the esophagus. Large hiatal hernias are commonly Type III.
