Surgical management of paraesophageal hernia
- Michael Rosen, MD
Michael Rosen, MD
- Section Editor — Hernia Surgery
- Professor of Surgery
- Cleveland Clinic Foundation
- Jeffrey Blatnik, MD
Jeffrey Blatnik, MD
- Assistant Professor of Surgery
- Washington University School of Medicine
- Section Editors
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
- 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 that mainly affects older adults, with a median age of presentation between 65 and 75 years [1-3]. Surgical management is indicated when medical management fails to control symptoms (eg, gastroesophageal reflux, dysphagia, regurgitation, anemia, dyspnea, epigastric, or abdominal pain) or when there is a complication (eg, bleeding, obstruction, or gastric volvulus) [4-8].
Surgical management of a paraesophageal hernia will be reviewed here. The anatomy, physiology, types, symptoms, and diagnosis of a hiatal hernia are discussed elsewhere. (See "Hiatus hernia".)
There are four types of hiatal hernias, three of which are paraesophageal hernias (figure 1). The four types of hiatal hernias can be distinguished by the hernia contents and the position of the gastroesophageal junction:
●Type I or sliding hiatus hernia is characterized by the displacement of the gastroesophageal junction above the diaphragm. The stomach remains in its usual longitudinal alignment, and the fundus remains below the gastroesophageal junction.
●Type II or "true" paraesophageal hernia results from a localized defect in the phrenoesophageal membrane where the gastric fundus serves as a lead point of herniation, while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament [7,8].
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- INDICATIONS FOR SURGICAL REPAIR
- PREOPERATIVE EVALUATION
- OPERATIVE APPROACHES
- TRANSABDOMINAL REPAIR
- Dissection of the hiatus and hernia sac
- Esophageal mobilization
- Closure of hiatal defect
- Anterior gastropexy
- Postoperative management
- TRANSTHORACIC REPAIR
- PATIENT OUTCOMES
- Mortality and morbidity
- - Reoperation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS