When a prolapse of a section of the stomach occurs into the diaphragmatic esophageal hiatus, it is called as a hiatal hernia. Incidentally discovered, most hiatal hernias are asymptomatic. It is rare that a hiatal hernia presents itself an acute life-threatening complication.
Acquired hiatal hernias are divided into traumatic hernias and non-traumatic hernias. Non-traumatic hernias are further divided into sliding hiatal hernia and paraesophageal hiatal hernia.
Complications and symptoms
In terms of complications, a hiatal hernia associated to esophagitis and may cause intermittent bleeding. It can also cause an esophageal ulcer or a Cameron ulcer or erosion. Associated paraesophageal hernia can cause an incarcerated hiatal hernia, which is rare. Hiatal hernias do not reveal any symptoms and may be a predisposal to reflux or worsen an existing reflux.
Conditions and diagnosis
Conditions that lead to a hiatal hernia are:
- Pregnancy ??? Hiatal hernias are common in women and occur when intra-abdominal forces exert during pregnancy
- Ascites of the abdomen
- Weakening of muscles due to age and also loss of elasticity of the muscles also due to aging ??? Hiatal hernias are prevalent in old people because of decreased tissue plasticity where the gastric cardia does not return back to its normal position
Chest radiographs and an upper gastrointestinal series with barium are suggested for the diagnosis of hiatal hernias. An esophageal barium study can diagnose a large hiatal hernia with accuracy. An upper gastrointestinal endoscopy also helps reveal complications such as esophageal ulcers and erosive esophagitis. Biopsy can also be conducted of any suspicious areas.
The surgery aims to close the wide esophageal hiatus by resecting the hernial sac. There four surgical options for the repair of a paraesophageal hernia:
Nissen fundoplication A laparoscopically performed procedure, in the Nissen Fundoplication the gastroesophageal junction requires a 360 deg. fundic wrap and along with repair of the diaphragmatic hiatus. The approach is transthoracic for patients who have undergone a previous Nissen Fundoplication procedure.
Toupet Procedure Similar to the Nissen Fundoplication, this procedure involves the placement of a 180 deg. wrap around.
Belsey Fundoplication A 270 deg. wrap is placed especially when there is minimal esophageal dysmotility. The procedure involves approximation of the right and left cura.
Hill Repair The posterior abdominal areas like the medial acruate ligament is anchored to the cardia of the stomach. This helps strengthen the anitreflux mechanism. The stomach may be tacked down into the abdomen to prevent it from moving up again.