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Hiatal and paraesophageal hernia

Hiatal hernia (HH) is a protrusion of abdominal contents into the chest through the opening in the diaphragm (‘hiatus’) normally occupied by the lower esophagus (Picture 1). It is caused by a combination of weak diaphragmatic muscle at the hiatus and a pressure difference between the chest (low pressure) and abdominal (high pressure) cavities, that pushes abdominal organs into the chest. The prevalence of HH is about 10% at age 40 and increases to about 50% in people aged over 70 years.

From the four types of HH shown above, type I hernia is the commonest (95% of total) and may not cause symptoms if small. In a type I hernia, the lower esophagus and part of the stomach move into the chest. As a result, the valve mechanism of the lower esophagus that prevents stomach acid and food from moving up towards the esophagus fails, causing symptoms of gastroesophageal reflux (heartburn and regurgitation).

Type II, III and IV hernias are paraesophageal hernias. Type II hernias are rare; as seen, the lower esophagus remains in the abdomen while part of the stomach herniates next to it. Type III hernias are the second commonest; the lower esophagus and a significant part of the stomach are in the chest. Type IV hernias evolve from untreated Type III hernias, when over time the entire stomach and sometimes other organs move into the chest. Patients with type III and IV hernias often have symptoms of gastroesophageal reflux. In addition, many will feel chest pain/pressure and shortness of breath after a meal, as a full stomach will push against surrounding chest organs.


Chronic symptoms

  • Gastroesophageal reflux symptoms (e.g. heartburn, regurgitation of food)
  • Shortness of breath, difficulty swallowing, dyspepsia, nausea
  • Anemia symptoms (tiredness, weakness) due to blood loss from ulcers in the herniated stomach
  • Sometimes even a large HH will produce no symptoms at all

Acute symptoms

Some patients with type III and IV HH will suffer acute complications such as volvulus (hernia contents twisting around themselves) or strangulation (compromised blood supply of hernia contents) (Picture 2). These patients will have acute chest and/or abdominal pain, inability to swallow and vomit.


HH can be an incidental finding of an imaging study performed for unrelated symptoms (e.g. chest xray, CT/MR scan of chest/abdomen, contrast swallow study). A CT scan will accurately define the anatomy and contents of a HH. Esophagoscopy (upper endoscopy) can be performed to demonstrate bleeding from mucosal ulcers or in the setting of acute symptoms to examine for viability of the esophagus.


  • Conservative/medical: a small percentage of patients who truly lack symptoms are at very low risk of complications and hence do not require surgery or other treatments. Elderly patients with reflux symptoms and significant comorbid medical conditions are treated with acid suppression.
  • Surgical: with the above exceptions, surgery is always indicated to control symptoms and prevent acute complications.

HH repair is performed laparoscopically through 5 small upper abdominal incisions. Patients with a history of previous upper abdominal surgery can also undergo laparoscopic surgery. Advantages of laparoscopy compared to ‘open’ surgery include less pain, faster recovery, better cosmetic result and avoidance of wound complications (infection, hernia).

At operation, hernia contents and the lower esophagus are returned to the abdomen. Rarely, this requires an esophageal lengthening procedure (Collis gastroplasty) (Picture 3). The diaphragmatic opening is narrowed to prevent recurrence, sometimes requiring mesh reinforcement (Picture 4).

In patients with gastroesophageal reflux, an anti-reflux procedure (fundoplication) is performed. In patients without reflux and in those having emergency surgery, the stomach is sutured to the diaphragm and lower abdominal wall.

Recovery: after elective surgery, patients are hospitalized for 2-4 days. Depending on repair technique, clear liquids are allowed 1-2 days after the operation. Ten to 15 days after surgery, all dietary restrictions are lifted. Pain responds to mild analgesics that are usually required for 1 week approximately. Lifting more than 5 kg is avoided for 2 months.

Complications: The commonest complications (affecting 20% of patients) are respiratory (e.g. pneumonia). Serious complications during surgery are rare.



  1. Ballian N, Luketich JD, Shende M, Levy RM, Awais O, Winger D, Jobe BA, Weksler B, Schuchert MJ, Landreneau RJ, Nason KS. A clinical prediction rule for morbidity and mortality after giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2013;145:721-9.
  2. Ballian N, Schuchert MJ, Luketich JD. Minimally Invasive Esophageal Procedures. Βιβλίο: Kaiser LR, Kron IL, Spray TL, eds. Mastery of Cardiothoracic Surgery. Philadelphia: Lippincott, Williams and Wilkins; 2013.



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