Hiatus Hernia

Overview

Where the oesophagus passes through the sheet of muscle called the diaphragm it passes through a natural hole in the muscle before heading into the stomach.  This hole can be either strong or weak and with age increasing weakness can effectively lead to a larger “hole” around the lower oesophagus.  A large hole or weakness here allows the oesophagus and stomach to move up and down abnormally.  This may predispose to acid reflux or cause no symptoms at all (most cases). 

Large hiatus hernias causing symptoms (including pain, vomiting or severe reflux) may require fixing surgically.  This can be done with a keyhole approach where a series of sutures is placed to tighten up the weakness around the lower oesophagus.

Hiatus hernias are also routinely repaired in bariatric surgery to prevent complications occurring afterwards with the new anatomy moving up and down into the chest.

Hiatus Hernia Basics

• An hiatus hernia is a weakness in the diaphragm where the oesophagus comes through into the abdomen to join the stomach from the chest
• An hiatus hernia is a weakness in the diaphragm where the oesophagus comes through into the abdomen to join the stomach from the chest
• The stomach is able to ride up into the chest which is an abnormal location for it
• There may be no symptoms, or there may be acid reflux, heartburn, difficulty swallowing food, pain or discomfort
• Occasionally a very severe rolling hiatus hernia may become incarcerated in the chest necessitating urgent life-saving surgery

Types of Hiatus Hernia

• Type I: "Sliding"
• Type II: "Rolling" or "Para-Oesophageal"
• Type III: "Mixed"
• Type IV: Contains other organs as well as stomach up in the chest

Normal Anatomy of Hiatus	Sliding Hiatus Hernia	Rolling Hiatus Hernia

Indications for Surgery

• Surgery is generally not indicated for Type I hiatus hernia unless directed primarily at reflux control (fundoplication) or as part of another procedure (e.g. gastric banding for obesity)
• For types II (& III/IV) (para-oesophageal hernia), surgery is usually indicated for symptoms related to the hernia
• The most common symptoms are chest pain, dysphagia, heartburn, regurgitation and shortness of breath
• Surgery for para-oesophageal hernia with no related symptoms is controversial (see below)

Surgery for Asymptomatic Para-Oesophageal Hernia

• This may be indicated for certain younger patients (e.g. under 60 years of age) who are fit for a major operation due to robust general health
• The goal of surgery in this group is prevention of future entrapment and strangulation of the stomach in the hiatus hernia which may be life-threatening
• The patient must be well informed and able to participate in the clinical decision making

Surgical Technique - Steps in Laparoscopic Hiatus Hernia Repair

• Hiatus Hernia repair is performed with laparoscopic surgery 95% of the time in our clinic
• Actual photos from laparoscopic repair are shown below. WATCH VIDEO

  	Stretched Diaphragm demonstrating large central defect (hiatus hernia)
  	The large defect is sutured closed
  	Mesh is placed over the repair to dissipate tension
  	The gastric fundus (floppy stomach) is formed into a wrap around the oesophagus to prevent reflux

• They may also pass into the common bile duct causing jaundice or pancreatitis and other diseases

Complications