Paraesophageal hernia: Clinical features and surgical repair
- Michael Rosen, MD
Michael Rosen, MD
- Section Editor — Hernia Surgery
- Professor of Surgery
- Cleveland Clinic Foundation
- Jeffrey Blatnik, MD
Jeffrey Blatnik, MD
- General Surgery Resident/Dudley P. Allen Research Scholar
- University Hospitals Case Medical Center
- Section Editors
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Professor of Surgery
- University of Pennsylvania
- Jeffrey Marks, MD
Jeffrey Marks, MD
- Section Editor — Minimally Invasive Surgery
- Professor of Surgery
- University Hospitals
- Case Medical Center
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'.)
- Hill LD. Incarcerated paraesophageal hernia. A surgical emergency. Am J Surg 1973; 126:286.
- Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967; 53:33.
- Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002; 236:492.
- Kaiser LR, Singal S. Diaphragm. In: Surgical Foundations: Essentials of Thoracic Surgery, Elsevier Mosby, Philadelphia, PA 2004. p.294.
- Miller JI Jr. Chapter 89. Bacterial infections of the lungs and bronchial compressive disorders. In: General Thoracic Surgery, 7th ed, Shields TW, LoCicero J, Reed CE, Feins RH. (Eds), Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia 2009. Vol 1, p.294.
- Kahrilas PJ. Hiatus hernia causes reflux: Fact or fiction? Gullet 1993; 3(Suppl):21.
- Peridikis G, Hinder RA. Paraesophageal hiatal hernia. In: Hernia, Nyhus LM, Condon RE (Eds), JB Lippincott, Philadelphia 1995. p.544.
- Davis SS Jr. Current controversies in paraesophageal hernia repair. Surg Clin North Am 2008; 88:959.
- Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive management of paraesophageal herniation in the high-risk surgical patient. Am J Surg 2001; 182:510.
- Pierre, AF, Luketich, JD. Laparoscopic repair of giant paraesophageal hernias. The cardiothoracic surgery network. www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html (Accessed on February 09, 2011).
- Casabella F, Sinanan M, Horgan S, Pellegrini CA. Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias. Am J Surg 1996; 171:485.
- Krähenbühl L, Schäfer M, Farhadi J, et al. Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach. J Am Coll Surg 1998; 187:231.
- Ponsky J, Rosen M, Fanning A, Malm J. Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair. Surg Endosc 2003; 17:1036.
- Low DE, Unger T. Open repair of paraesophageal hernia: reassessment of subjective and objective outcomes. Ann Thorac Surg 2005; 80:287.
- Puri V, Kakarlapudi GV, Awad ZT, Filipi CJ. Hiatal hernia recurrence: 2004. Hernia 2004; 8:311.
- de la Fuente SG, Khuri SF, Schifftner T, et al. Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database. J Am Coll Surg 2006; 202:78.
- Rathore MA, Andrabi SI, Bhatti MI, et al. Metaanalysis of recurrence after laparoscopic repair of paraesophageal hernia. JSLS 2007; 11:456.
- Ferri LE, Feldman LS, Stanbridge D, et al. Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach? Surg Endosc 2005; 19:4.
- Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000; 190:553.
- Frantzides CT, Carlson MA, Loizides S, et al. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc 2010; 24:1017.
- Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 2002; 16:745.
- White BC, Jeansonne LO, Morgenthal CB, et al. Do recurrences after paraesophageal hernia repair matter? : Ten-year follow-up after laparoscopic repair. Surg Endosc 2008; 22:1107.
- Carlson MA, Condon RE, Ludwig KA, Schulte WJ. Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg 1998; 187:227.
- Geha AS, Massad MG, Snow NJ, Baue AE. A 32-year experience in 100 patients with giant paraesophageal hernia: the case for abdominal approach and selective antireflux repair. Surgery 2000; 128:623.
- Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg 2002; 137:649.
- Müller-Stich BP, Holzinger F, Kapp T, Klaiber C. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Surg Endosc 2006; 20:380.
- Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg 2006; 244:481.
- Lee YK, James E, Bochkarev V, et al. Long-term outcome of cruroplasty reinforcement with human acellular dermal matrix in large paraesophageal hiatal hernia. J Gastrointest Surg 2008; 12:811.
- Mitiek MO, Andrade RS. Giant hiatal hernia. Ann Thorac Surg 2010; 89:S2168.
- Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg 2011; 213:461.
- Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23:1219.
- Obeid NM, Velanovich V. The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores. Ann Surg 2013; 257:655.
- Luketich JD, Nason KS, Christie NA, et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2010; 139:395.
- Larusson HJ, Zingg U, Hahnloser D, et al. Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg 2009; 33:980.
- Poulose BK, Gosen C, Marks JM, et al. Inpatient mortality analysis of paraesophageal hernia repair in octogenarians. J Gastrointest Surg 2008; 12:1888.
- Schauer PR, Ikramuddin S, McLaughlin RH, et al. Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg 1998; 176:659.
- CLINICAL FEATURES
- INDICATIONS FOR SURGICAL REPAIR
- TECHNICAL INSIGHTS
- Dissection of the hernia sac
- Closure of hiatal defect
- Anterior gastropexy
- POSTOPERATIVE MANAGEMENT
- PATIENT OUTCOMES
- Laparoscopic versus open repair
- Mesh repairs
- Mortality and morbidity
- REOPERATIVE CONSIDERATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS