A paraesophageal hernia is an uncommon type of hiatal hernia. It includes a peritoneal layer that forms a true hernia sac, distinguishing it from the more common sliding hiatal hernia. Surgical management is indicated when medical management fails to control symptoms of gastroesophageal reflux that may be related to the paraesophageal hernia, or when there is an emergent complication [1-5].
The general principles for the diagnosis and surgical management of a paraesophageal hernia will be reviewed here. The anatomy, physiology, types, and symptoms of a hiatal hernia are discussed elsewhere. (See "Hiatus hernia".)
Hiatal hernias are classified by type: type I is a sliding hernia and types II, III, and IV are paraesophageal hernias. Paraesophageal hernias account for approximately 5 percent of all hiatal hernias and frequently are asymptomatic or associated with vague and intermittent symptoms of gastroesophageal reflux [6,7]. (See "Hiatus hernia", section on 'Classification' and "Clinical manifestations and diagnosis of gastroesophageal reflux in adults".)
A paraesophageal hernia, a true hernia with a hernia sac, is characterized by an upward dislocation of the gastric fundus alongside a normally positioned gastroesophageal junction [4,5]. The gastric fundus and abdominal viscera protrude into the mediastinum through the defect in the diaphragm. In contrast, a sliding hernia does not have a hernia sac and slides into the chest since the gastroesophageal junction is not fixed inside the abdomen.
Most patients with a paraesophageal hernia are asymptomatic . Approximately one-third of patients have endoscopic evidence of gastritis, gastric ulceration, or esophageal reflux. Gastric ulcers result from poor gastric emptying and torsion of the gastric wall. (See "Hiatus hernia", section on 'Clinical features'.)