Hiatus hernia is the protrusion of abdominal contents through a widened diaphragmatic hiatus, typically involving stomach but may include omentum, colon, small bowel, pancreas and spleen.
Presentation & investigation
Small sliding hiatus hernias are most commonly associated with gastro-oesophageal reflux including both acid and volume reflux symptoms.
Large hernias are more likely to present with other symptoms including epigastric or chest pain, dyspnoea, dysphagia, early satiety, nausea, vomiting and aspiration. They can commonly cause iron deficiency anaemia. Rarely, gastric volvulus can occur resulting in obstruction (a surgical emergency requiring urgent decompression).
Gastroscopy is the most useful investigation. Large hiatus hernias may be seen on chest x-ray. CT scanning, barium study, pH and manometry and gastric emptying studies can help define the anatomy, confirm reflux and exclude other conditions (e.g. oesophageal motility disorders, gastroparesis).
The surgical approach
Asymptomatic small sliding hernias do not require surgery. In those with ongoing acid reflux symptoms not controlled with conservative measures and medical management hiatus hernia repair and fundoplication is an effective option and should be considered or as an alternative to longer term medication.
Surgery can almost always be performed laparoscopically with low morbidity in most patients. Complications of fundoplication include dysphagia, inability to belch, gas bloat and increased flatulence. These can be reduced by performing a partial fundoplication without compromising reflux control. Patients may need to follow a modified diet slowly transitioning to solid diet over two months. They should avoid heavy lifting, straining and strenuous exercise during this time whilst the tissues are regaining strength.
The natural history of large hernias is to progress in size with increasing symptoms. Surgical repair is usually recommended and even in the elderly, provided there are no severe cardio respiratory co-morbidities. Fundoplication is often not necessary in those without reflux symptoms.
Recurrence rates for traditional suture repair are high. Absorbable biological mesh has not been shown to be more effective. Permanent mesh reinforcement does decrease the risk of recurrence as with other forms of abdominal wall and inguinal hernias.
Large and or recurrent hiatus hernias are more technically difficult to repair but can usually be done laparoscopically.
Obesity is a major contributing factor in hiatus hernia initially and with recurrence post surgery. Achieving and maintaining significant weight loss is highly desirable. Combining hiatus hernia surgery with a bariatric procedure is another alternative.
- Medical management predominates for small hiatus hernias.
- Consider surgery for failed medical management, or as an alternative to long-term medication.
- Surgical repair is mostly laparoscopic.
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