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Esophagus: Hiatal Hernia Types Sliding Hernia Type I : Gastroesophageal (GE) Junction Herniated Above the Diaphragm Most Common Hiatal Hernia (95%) Paraesophageal/Rolling Hernia Type II : Part of the Stomach Herniated Above the Diaphragm Next to a Normally Positioned GE Junction Least Common Hiatal Hernia Type III : Combined Type I & Type II Most Common Paraesophageal Hernia (90%) Type IV : An Intraabdominal Organ Other than the Stomach is also Herniated Through the Hiatus (Spleen/Colon) Hiatal Hernia Types 1 Presentation Symptoms Sliding Hernia Highly Associated with GERD (50-94%) from GE Junction Incompetence & Impaired Esophageal Emptying Most are Asymptomatic & Complications are Rare Large Hernias Will Have GERD Symptoms (Heartburn, Regurgitation & Dysphagia) Paraesophageal Hernia GERD Symptoms are Less Common than With Type I Pain (Epigastric/Substernal) Postprandial Fullness Nausea & Vomiting Complications Rare in Type I Gastric Volvulus *See Stomach: Gastric Volvulus Cameron Ulcers Ulcer of Herniated Portion Can Cause Chronic Blood Loss & Anemia *See Stomach: Peptic Ulcer Disease Impaired Pulmonary Function From Large Hernia in Thoracic Cavity Compressing the Lung Diagnosis & Preoperative Evaluation Diagnosis Usually Diagnosed Incidentally Intraoperatively May See Dimpling Anterior to Esophagus Preoperative Testing Barium Esophagram Critical for Diagnosis & Description of Anatomy The Most Sensitive Diagnostic Test Upper Endoscopy Critical to Rule Out Malignancy & Evaluate Barretts Esophagus, Esophagitis or Ulcers Manometry Required Preoperatively to Evaluate for Concurrent Motility Disorders CT Scan Evaluates Anatomy if a Type IV is Suspected Esophagram Sliding HH 2 Endoscopy Sliding HH 2 Manometry Hypotensive Contraction 2 CT Showing Large Type IV HH 3 Treatment Sliding Hernia Treatment Tx: PPI & GERD Management Paraesophageal Hernia Treatment ASx : Medical Management Historically Recommended Prophylactic Surgery to Prevent Emergent Complications Now Mostly Advised Against Consider Prophylactic Surgical Repair if Progressing or Young/Fit Sx : Paraesophageal Hernia Repair Includes: Repair of Crural Defect & Fundoplication Repair the Crural Defect Before Fundoplication *See Esophagus: Fundoplication Requires Complete Dissection & Resection of the Hernia Sac Repair Defect with Permanent Suture Use Biologic Mesh if Large Similar Overall Complication Rate to Polypropylene Although Risk of Dysphagia (Biologic) is Preferred Over Erosion (Polypropylene) References Lebenthal A, Waterford SD, Fisichella PM