Also known as hiatal hernia, a hiatus hernia occurs due to the prolapse of the stomach through the esophageal hiatus. The esophagus connecting the mouth and the stomach passes through a gap in the diaphragm, called hiatus. The weakened area of the hiatus causes clamping of the entry of the stomach. Due to this, acidic juices are pushed up into the esophagus causing reflux (GERD). A painful and burning sensation along with chest pain extending below the shoulder blades is experienced by the patient. A hiatal hernia is normally discovered when a patient is being evaluated for GERD.
Complications and causes
Hiatus hernias are rarely life-threatening but are usually asymptomatic. There are some complications of the hiatal hernia that cannot be ignored. Some complications of the hiatal hernia are:
- Cameron ulcers
- Bleeding from the esophagitis
- Distinct esophageal ulcer
- Incarcerated hernia - normally associated with paraesophageal hernia
The causes of hiatal hernia can be:
- Abdominal ascites
- Weakening of muscles due to aging
- Fibre-depleted diet leading to chronic constipation
- Fibrosis of longitudinal muscles due to shortening of the esophagus
Barium upper gastrointestinal series - this reveals:
- Free reflux of barium (occasional)
- Wide hiatus displaying the gastric folds
- Outpouching of the barium
- Difference between a sliding hernia and a paraesophageal hernia
Upper GI endoscopy - this helps reveal:
- Incidental presence of a hiatal hernia
- Presence of erosive esophagitis, tumor, Barrett esophagus, tumors
- Biopsy of abnormal area
Prophylactic surgery may be carried out to repair the paraesophageal hernia to prevent complications. Three surgical procedural options are available for the repair of a hiatal hernia:
Laparoscopic Hill repair surgery attempts at the restoration of normal anatomy and functionality by repairing both the anti-reflux valve or the LES and the hiatal hernia. Five small incisions are made to perform the surgery, after patient has been laid in the low lithotomy position, compression devices are affixed to the legs. 0.25% bupivacaine is used to anaesthetize the port sites. Tension-free approximation of the posterior phrenoesophageal bundle to the preaortic fascia is accomplished after the esophagus and the posterior gastric fundus are mobilized. The posterior stomach wall is anchored to the left side of the preaortic fundus thus aligning the posterior phrenoesophageal bundle and allowing placement repair sutures.
In the Nissen fundoplication procedure, incision is carried out in the upper abdomen. Two 10 mm ports and three 4 mm ports allow exposure of the gastroesophageal junction. A retractor is used to elevate the liver. The esophagus is exposed and the stomach is mobilized. The small vessels present between the stomach and spleen are then divided. The fundus or upper portion of the stomach is mobilized and used for fundoplication. Scar tissues present in the esophagus are extracted and the hernia reduced into the abdomen.
Laparoscopic Besley fundoplication requires the approximation of the right and left cura to complete the procedure. Gas bloating and postoperative dysphagia are avoided with the use of a 270 deg, wrap.