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Hiatus hernia

Section: UGI Sub-section: Gastric and Oesophagus Curriculum: Curriculum, page 94

Definition

  • Extension of the peritoneal cavity into the thoracic cavity through the Oesophageal Hiatus of the Diaphragm

Incidence

  • Overall prevalence in the general population is estimated at 20%
  • 80% of pts with GORD
  • Type I = 95%
  • Type II (pure rolling hernia) is a rare finding
  • Type III mean age = 60 yo
    • F > M 4:1
  • Type IV = Very rare
    • Mean age 50-60yrs

Classification

  • Type I: Sliding
    • Proximal herniation of GOJ
  • Paraoesophageal
    • Type II: Rolling
      • Paraoesophageal hernia of fundus
      • GOJ in normal position
      • The relative negative pressure in the thorax facilitates visceral migration
    • Type III
      • Combined herniation of both GOJ & fundus
    • Type IV
      • Large defect with herniation of other organs
      • e.g. Colon, Spleen, Small Bowel

Aetiology

  • ? Congenital paraoesophageal defect
  • ? Degenerative
    • Structural deterioration of the phrenoesophageal ligament (continuation of endoabdominal fascia)
    • → Leads to excessive cranial movement / oesophageal shortening on swallowing
    • Affected by pregnancy, obesity, ↑ intra abdo pressure, age

Clinical Presentation

  • Many asymptomatic
    • Estimated that only ≈ 10% of pts with Sliding Hiatus Hernia have symptoms
    • Paraoesophageal more likely to be symptomatic & more likely to become incarcerated
  • GORD symptoms
    • Dysphagia, reflux, heartburn, epigastric pain, vomiting
  • Respiratory
    • Cough / pneumonia
    • May get SOB in giant hiatus hernia due to lung compression
    • SOB also from Anaemia or compression of the Left Atrium and Pulmonary Veins
  • ± Anaemia due to
    • Erosive gastritis
    • Ischaemia
    • Cameron ulcers
  • Borchardt’s Triad = Classic for Gastric volvulus
    • Severe epigastric pain
    • Retching without vomiting
    • Inability to pass a nasogastric tube
  • Other Sx of Large Type 2-4 Hiatus hernia
    • Dysphagia/odynophagia, post prandial fullness, early satiety, regurgitation, breathlessness, weight loss

 Cameron Ulcer

  • Ulcers in the hiatal sac of patients with hiatal hernia
    • Tend to be at, or near, where stomach folds constricted by the diaphragm
    • Thought caused by mechanical trauma at the level of constriction of the diaphragm
  • Uncommon (5.3% incidence)
  • Usually asymptomatic
    • Can cause anaemia
    • Symptomatic UGIB rare
  • Usually an incidental finding during upper endoscopy in patients with hiatal hernia
  • Can manage with Fe+ replacement, PPIs
    • May require surgical correction of hernia

Pathophysiology

  • NB: Normal pts - degree of “physiological herniation”
    • Oesophagus shortens in normal swallowing and elevates the GOJ
  • In pathological Hiatus Hernia
    • Widening of the hiatus & thinning/lengthening of the Phreno-oesophageal membrane
  • Hiatus hernia predisposes GORD by the following mechanisms:
    • Interferes with buttressing of the crura
    • Loss of acute angle of His
    • Impaired clearance of refluxed acid from oesophagus, due to loss of anchoring of distal oesophagus & pressure change
  • A giant hernia results from progression of a simple sliding &/or rolling hernia
    • Entire stomach migrates up into the chest by rotating 180°
    • Get intrathoracic stomach with organoaxial volvulus

Investigations

  • Important to understand motility of the oesophagus pre-surgical intervention
  • If planning to add an anti-reflux procedure in with repair, it is thought unnecessary to carry out pH studies
    • Placement of catheters in these patients can be difficult
  • CXR
  • Barium studies
  • Endoscopy:
    • Look at proximal extent of rugal folds, > 2cm beyond hiatus using retroflexed scope
    • Graded using the Hill classification

Hill Classification

  • Grading system for hiatus hernias using retroflexed scope, (seeing if GOJ grips scope)
  • Hill 1
    • Tight approximation of the gastroesophageal fold against the endoscope.
  • Hill 2
    • Loose grip of the gastroesophageal valve around the endoscope, with intermittent opening.
  • Hill 3
    • Presence of a hiatal hernia, characterized by a visible gap between the squamocolumnar junction and the diaphragmatic crura.
  • Hill 4
    • Large hiatal hernia with a wider diaphragmatic opening.

Management

Management of Acute Obstruction/Herniation

  • Large hiatus hernias get two points of twisting/volvulus - see Gastric volvulus
  • Gives intermittent or ongoing obstruction
  • Can lead to focal/global ischaemia
  • Risk of large HH becoming symptomatic
  • Presentation
    • Severe pain
    • Perforation
    • Obstruction/volvulus
  • Resuscitate
    • IV fluids
    • NGT if able (Don’t push this)
    • Correct electrolyte abnormality
  • Determine if ischaemia or infarction
    • Response to resus, Ongoing pain, WCC/CRP, gas on CT in stomach wall or portal venous system
  • Urgent decompression
    • Endoscopy – allows inspection for necrosis and decompression
  • Surgery
    • Can be delayed 2-3 days as staged procedure after decompression and correction of physiological derangements
  • If unable to decompress or concern for ischaemia
    • Lap or open reduction
      • Either hiatus hernia repair
      • Or can pull down stomach, place NG tube, pexy stomach (suture or gastrostomy)
    • If ischaemia and resection required
      • may need 2 stage surgery
        • Resect and place drain + NGT
        • Then return for anastomosis - with UGI surgeon

Management for Hernia type

  • Type I
    • Asymptomatic type I patients can be managed conservatively
    • For symptomatic pts: Laparoscopic approach favoured
  • Type II-IV:
    • Surgery traditionally advocated in all pts
      • Due to risk of complications
      • Bleeding, infarction, perforation
      • But more recent data suggest that complications may be less common than initially thought
        • Prev described mortality risk 30% of acute presentations
          • Probably more like 5%
      • So depends on nature and severity of obstructive symptoms
    • Treatment only if symptomatic may be appropriate
      • Balance nature of symptoms vs surgical risk

Principles of Surgical Management

  • Reduction of hernia contents
  • Herniotomy (excision of sac)
  • Cruroplasty (closure of defect) ± mesh
    • Mesh gives reduced chance of recurrence but higher risk of oesophageal erosion in paraoesophageal hernia repair
    • Biologic mesh is probably best
  • Fundoplication

Laparoscopic

  • Higher recurrence rate (41% of Type III hernias by 2yrs)
  • But has benefits of both thoracotomy and laparotomy approach
  • Vs Open
    • NB: Risk of Vagus injury
    • Lower recurrence rate (15% at 3yrs)

Surgical Differences for Large Hiatus Hernias

  • Circumscribe and excise hernia sac
  • Focus is on the crural repair
    • Often muscle is deficient
  • May require adjunct (mesh) or bolster (pledget)
    • Avoid non-absorbable mesh, esp. circumferential
  • Add a drain
  • Place NG tube post-op

Hiatus Hernia Repair – Op Viva

  • Mobilize & divide short gastrics to expose left pillar
  • Will now need to divide hernial sac anteriorly, continue to free from mediastinal attachment freeing stomach
  • Transect sac circumferentially at hiatus – posterior dissection - oesophagus & anterior vagus intimately related (maybe use a lighted bougie)
  • Remove as much sac as possible but be safe
  • Cruroplasty
  • Anti-reflux procedure

Prognosis/Natural History

  • Type II or III hernias tend to progressively worsen
  • For giant hernia:
    • Up to 20% → Acute obstruction from torsion/volvulus → Ischaemia, perforation, sepsis
    • 20% mortality for emergency operative repair of incarcerated paraoesophageal hernia
    • Surgery 90% effective

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