Version July 2025
INTRODUCTION —
Paraesophageal hernias (PEH) are most common in older adults, particularly females, although they are increasingly seen in younger people and males. Consequently, PEHs are becoming increasingly common as the population ages. Kyphosis is a major risk factor, and these hernias are also more common in people with a history of other abdominal hernias such as inguinal, umbilical, or ventral hernias [1-5].
Unlike sliding hiatal hernias, there is no medical management for PEH. Surgical treatment of PEH will be reviewed here. The anatomy, physiology, types, symptoms, and diagnosis of a hiatal hernia are discussed elsewhere. (See "Hiatus hernia".)
DEFINITION —
There are four types of hiatal hernias, three of which are PEHs (figure 1). The four types of hiatal hernias can be distinguished by the hernia contents and the position of the gastroesophageal junction (GEJ) [6]. Sliding hernias are associated with gastroesophageal reflux disease (GERD), but only a PEH has the potential to develop acute hernia-related complications such as obstruction, ischemia, or perforation. When more than 50 percent of the stomach has herniated into the chest, a PEH is often referred to as a "giant" PEH.
●Type I or sliding hiatus hernia is characterized by the displacement of the GEJ above the diaphragm with a part of the fundus of the stomach also in the mediastinum. Critically, the herniated part of the fundus remains below the GEJ.
●Type II or "true" PEH is extremely rare, and results from a localized defect in the phrenoesophageal membrane where the gastric fundus herniates into the mediastinum and is adjacent to the esophagus while the GEJ remains in the abdomen [7,8].
●Type III or "mixed" PEH is the most common type of PEH and is characterized by having both the GEJ and the fundus of the stomach in the mediastinum. A mixed PEH distinguishes from a sliding hernia in that the fundus of the stomach is located above the GEJ, adjacent to the esophagus (and thus "para," or next to, the esophagus).
●Type IV PEH is a Type III PEH where another organ in addition to the stomach has herniated into the mediastinum. Most commonly, this is the colon but can also be the spleen, pancreas, or small intestine. Omentum herniated into the mediastinum is common and does not qualify as a Type IV hernia.
The prevalence of a hiatal hernia increases with age. Overall, more than 90 percent of hiatal hernias are sliding hernias (Type I). While GERD symptoms are much more common in patients with sliding hernias [9], patients with heartburn symptoms can find symptom relief with acid-suppressing medications. However, limited data on the natural history of a hiatal hernia suggests that over time a sliding hernia can become a PEH, and a PEH can increase in size [10]. Evidence also indicates that, when sliding hernias progress into PEHs, GERD symptoms dissipate in some patients [10].
More common PEH-related symptoms include postprandial chest discomfort and fullness, which can only be addressed with surgical PEH repair. Currently, surgical management is indicated in any patient with a symptomatic PEH [11]. However, newer evidence suggests that asymptomatic patients may also benefit from elective repair of a PEH to avoid serious PEH-related complications [7,8,11-15]. (See 'Elective presentation' below.)
In contrast to a sliding hiatal hernia, which is not associated with serious complications, a PEH can lead to life-threatening complications related to gastric volvulus [16]. The two types of volvuli are organo-axial, where the stomach has flipped upside down in the chest and is rotated along its long axis, and meso-axial, where the stomach is folded in half along its midpoint and short axis (figure 2). Complications of a PEH are related to the size of the PEH and the degree of volvulus, with a complete intrathoracic stomach with volvulus being at greatest risk for a complication requiring urgent or emergency intervention [14]. (See "Gastric volvulus in adults" and 'Urgent presentation' below.)
ELECTIVE VERSUS URGENT SURGICAL REPAIR —
Surgical repair of a PEH may be indicated electively or urgently depending the acuity and severity of the patient's presentation.
Elective presentation — Elective PEH repair is recommended for all healthy patients given newer data showing improved life expectancy compared with a watchful waiting approach, even in asymptomatic patients.
The suggested management of a PEH has undergone changes over time. In the 1960s and 1970s, the recommendation was for surgical repair of a PEH upon diagnosis, given the risk of serious or catastrophic complications. This risk was estimated to be approximately 30 percent in two series by prominent surgeons [12,13]. In 2002 the paradigm changed after the publication of a Markov analysis of hypothetical patients with a PEH [11]. This analysis showed that for someone 65 years or older with an asymptomatic Type II or III PEH, watchful waiting rather than elective surgical repair was the preferred strategy based on quality-adjusted life years. Subsequently, the current approach of only repairing a PEH in symptomatic patients was adopted worldwide. However, most physicians were unaware of the limitations of this analysis in that patients under 65 and those with a Type IV hernia were not modeled and the findings of the study did not apply to them. Further, the authors recognized that if the mortality for elective repair dropped to ≤0.5 percent, then elective repair would become the preferred strategy over watchful waiting [11].
Much has changed since the 2002 study that led to the adoption of watchful waiting in patients with few or no PEH-related symptoms. In particular, the variables used in that Markov model were from published reports in the late 1990s, where most elective PEH repairs were done as open transabdominal or transthoracic repairs with a mortality rate of approximately 1.4 percent. In contrast, most current PEH repairs are done laparoscopically, and the mortality rate of elective repairs has dropped below 0.5 percent in numerous series [14]. An updated Markov model using current values for key variables such as the elective repair mortality rate has now changed the paradigm again. This study confirms that elective repair of an asymptomatic PEH in healthy people aged 40 to 90 leads to an increase in life expectancy over watchful waiting, and is now the preferred management strategy [14]. Further, elective repair remains the preferred strategy in most people with a PEH even in the setting of comorbid conditions [15]. In addition to the low mortality for elective repair, a major factor in the new recommendations from the updated Markov analysis is the continued high mortality rate when emergency repair is necessary for PEH-related complications [17].
It remains debated if someone with a large PEH can be truly asymptomatic since often these individuals have subtle, hernia-related symptoms such as chest pain or pressure with meals, early satiety, or dyspnea on exertion. Patients have also modified their lifestyle over time to avoid symptoms, and this requires careful history-taking focusing on these changes to elucidate the true symptoms. Numerous studies have associated PEH repair with improvement in quality of life (QOL) measures such as relief of chest discomfort and respiratory and reflux symptoms [18-20]. Importantly, the presence of symptoms is a risk factor for the development of PEH-related complications such as obstruction, ischemia, and perforation as well as the need for surgical intervention, hence patients should be questioned carefully about the existence of symptoms [21]. Most symptomatic patients, even with comorbid conditions, will have a benefit in life expectancy with elective PEH repair. Similar benefits in life expectancy occur in patients with a PEH and anemia or Cameron ulcers, and such findings are also strong indications for PEH repair [15].
An issue that comes up frequently is whether elective repair is appropriate in older patients with a PEH. Often, older patients have been advised to not have their PEH repaired given concerns regarding operative morbidity and mortality, and this approach has led to many of these patients presenting acutely with PEH-related complications. Two large database studies highlight this issue:
●The first used the Society of Thoracic Surgeons (STS) database to show that among 19,122 patients with a PEH, those undergoing urgent or emergency repairs had more comorbid conditions and were older, and specifically much more likely to be over 80 years old [22]. The rate of urgent or emergency surgery was 8.6 percent in patients <80, increased to 23.6 percent in those aged 80 to 89, and was 49.2 percent for patients ≥90 years old. On multivariable analysis, nonelective PEH repair was a significant independent predictor of the composite outcome of mortality or major morbidity (odds ratio 2.06, p <0.001). In the entire cohort, they noted a sevenfold increase in operative mortality associated with urgent or emergency surgical intervention compared with elective PEH repair, and the mortality rate (10 percent) was particularly striking in patients aged 80 years and older. They concluded that despite the increased risk, elective repair should be considered in the older adult population given the consequences associated with the development of acute PEH-related complications in this group of patients.
●The second study reached similar conclusions using the Nationwide Readmissions Database [23]. Among 46,450 patients who had PEH repair from 2016 to 2018, 11.7 percent were octogenarians, and compared with nonoctogenarians, where less than one in five patients had a nonelective operation, nearly one-half of the octogenarians underwent an urgent or emergency operation. Their data confirmed that undergoing nonelective PEH repair was independently associated with mortality, but being an octogenarian was not an independent predictor of mortality. As such, elective repair should be considered for older adult patients.
Other smaller studies also support the role of elective PEH repair in older patients:
●A retrospective study of 534 patients undergoing PEH repair showed that age ≥80 years was associated with more postoperative complications but not severe complications (Clavien-Dindo Grade ≥IIIa) (table 1). Further, patients ≥80 years of age did not have more readmissions or early recurrences [24].
●Another study evaluated the outcomes of PEH repair and showed that compared with younger patients (mean age 58.5 years), very old patients (mean age 83 years) had an increased length of stay and a higher major morbidity rate but not a higher mortality rate. Importantly, both groups benefited from surgery, with a significant improvement in their QOL. The authors concluded that it is safe to perform laparoscopic PEH repair in older adults at experienced centers [25].
The findings of these studies have important implications since the number of people aged 80 and above tripled from 1990 to 2019 and is projected to triple again from 2019 to 2050 [23]. This age group is more likely to have comorbid conditions and is the group that most commonly undergoes nonelective PEH repairs with an associated high morbidity and mortality rate. Importantly, the assumption of the older Markov model in 2002 that the rate of disease progression in patients with a PEH was constant over time may be incorrect. Instead, the risk of progression to PEH-related complications may be increased in older patients [11,22,23]. The benefit of avoiding an urgent or emergency operation in older patients is demonstrated in the updated Markov model and represents an important paradigm change in the management of all patients with a PEH [14].
Urgent presentation — Emergency surgical repair is associated with a significant increase in morbidity and mortality but is required for acute gastric volvulus not responsive to endoscopic or nasogastric decompression, or for full-thickness gastric necrosis or perforation.
In patients who present to the emergency room with acute complications of a PEH, the initial steps include fluid resuscitation and an evaluation for evidence of ischemia or perforation by lab tests and imaging. (See "Gastric volvulus in adults", section on 'Acute symptoms'.)
Patients without gastric ischemia or perforation — Most patients present with obstructive symptoms of nausea and retching, and initial management includes gastric decompression. Typically, this is done with a nasogastric tube (NGT) placed in the emergency department. If the NGT is unable to be placed into the stomach at the bedside, it should be placed endoscopically. Gastric decompression reduces the distension and improves perfusion, and in most cases will prevent the need for emergency operation.
Ideally, the NGT would be placed into the distal stomach, but most commonly it coils in the herniated stomach above the diaphragm. Even in this location, it usually allows for gastric decompression and resolution of the edema that causes the outlet obstruction. About 85 percent of patients who present acutely with PEH-related complications can be managed with NGT decompression [26]. Typically, these patients are watched closely and taken for semielective PEH repair 72 to 96 hours later. This allows the gastric wall thickening and edema that is almost always present to dissipate and facilitates PEH repair rather than needing to pexy or place gastrostomy tubes. During the coronavirus disease 2019 (COVID-19) pandemic, it became clear that many patients could be sent home on a full liquid diet until they were able to have an elective PEH repair. The volvulus in these patients was still present, confirming that it was not the volvulus itself causing the acute obstruction. Rather, gastric distension from eating a large or heavy meal in the setting of a PEH with volvulus typically leads to the acute problem.
In patients with obstructive symptoms related to a PEH who are too frail for operative intervention, endoscopic detorsion of the volvulus with the placement of two percutaneous endoscopic gastrostomy tubes can be attempted [27]. This approach does not preclude a formal hernia repair at a later time. (See "Gastric volvulus in adults", section on 'Poor surgical candidates'.)
Patients with gastric ischemia or perforation — Gastric ischemia in patients with a PEH is related to distension and localized compromise of perfusion in the gastric wall related to Laplace's law. Ischemia usually starts in the mucosa and over time can extend to full-thickness injury. If there is evidence of full-thickness necrosis or perforation, then emergency surgical intervention will be required after initial resuscitation and administration of broad-spectrum antibiotics. In patients who have been on acid-suppressive medications, antifungal therapy should also be considered. Traditionally, these emergency operations have been done open, but increasingly, these are being performed laparoscopically or robotically.
●Typically, the area of necrosis or perforation is located in the fundus near the GEJ, and in some cases, this area can be excised with a wedge-fundectomy Collis gastroplasty, done not to add esophageal length but to excise the ischemic tissue and allow a partial fundoplication to be accomplished with repair of the PEH. (See 'Esophageal mobilization for intra-abdominal esophageal length' below.)
●Extensive gastric necrosis may require an extended gastrectomy, perhaps with Roux-en-Y esophagojejunostomy. Resection of the proximal stomach with esophagogastrostomy alone should be avoided since this leads to severe gastroesophageal reflux. Since the indication for emergency operation is usually full-thickness necrosis or perforation, typically, a standard PEH repair is not feasible. However, when there is sufficient fundus after the removal of the ischemic or necrotic areas, the original procedure as described by Nissen can be used for reconstruction. In this procedure, the esophagus is anastomosed to the proximal stomach, and the anastomosis is embedded within the fundus by folding the fundus up and around the anastomosis on each side [28].
●In cases where suspected full-thickness necrosis turns out to be only partial, consideration should be given to a standard PEH repair with partial fundoplication. Gastropexy is also an option, particularly if the fundus is too edematous to create a fundoplication. Gastropexy dates back to the era of Nissen, and the technique has been revised over more recent years [29,30]. While gastropexy with or without percutaneous gastrostomy tubes has been used during PEH repair, these patients are at risk for postoperative reflux, and long-term outcomes are not well established. Further, unless the patient is unstable, there is little evidence to suggest that a few more minutes in the operating room to complete a fundoplication has a significant impact on morbidity or mortality, but a recurrence or ongoing reflux after surgery could have a major impact on the patient's QOL and need for reoperation. (See 'Gastropexy' below.)
PREOPERATIVE EVALUATION
Patient history — Evaluation of patients with a PEH starts with understanding the presence or absence of symptoms.
Patients with a PEH may have typical gastroesophageal reflux disease (GERD) symptoms such as heartburn or regurgitation, but these are less common than PEH-related symptoms such as chest fullness or discomfort, particularly with meals, episodic epigastric or chest pain, or dyspnea, particularly after meals. Commonly, patients have learned that chest fullness or discomfort is worse after large, heavy meals, and have modified their habits to eating smaller and lighter meals.
Dysphagia can be present and is an important symptom to elicit since it can influence evaluation and management. When dysphagia is present it is important to determine whether the dysphagia is for solids only, or for both solids and liquids. Rarely, patients with a PEH can have concomitant achalasia, and if present, the achalasia should be identified preoperatively and treated at the time of surgical repair.
Anemia is common in patients with a PEH. A study of 394 patients presenting for PEH repair documented anemia in 25.6 percent, and the likelihood of anemia was increased in those with larger hernias [31]. The authors noted that the presence of anemia was a risk factor for an increased length of hospital stay and all-cause postoperative mortality. Importantly, the resolution of anemia with PEH repair has been documented in numerous studies dating back to the 1960s [31-33]. Further, it has been shown that there is also an improvement in quality of life in patients with anemia after PEH repair [34].
Anemia can be associated with Cameron lesions. Cameron lesions are found endoscopically in about 6 percent of patients with a PEH. Like PEH-related symptoms, the endoscopic finding of Cameron lesions is a significant risk factor for the development of PEH-related complications in patients managed with watchful waiting [21]. Further, the resolution of Cameron lesions is superior with PEH repair compared with medical management [35].
In addition to symptoms, it is important to understand any prior esophageal or foregut evaluation or interventions and the patient's past medical history, including any comorbid cardiac and/or pulmonary diseases.
Testing — Prior to surgical repair of a PEH, all patients should undergo endoscopic evaluation of the upper digestive tract and a barium swallow study. A manometry study is optional and only necessary if a complete fundoplication is planned.
●Upper endoscopy – Prior to surgical repair, all patients diagnosed with a PEH should undergo endoscopic evaluation. During upper endoscopy, a sliding hiatal hernia is best visualized using a retroflexion maneuver (figure 3).
However, with a large PEH, the initial indication of a hernia is often the inability to advance the scope easily down to the pylorus related to the volvulus that accompanies a large PEH. In patients with a PEH, the scope typically curls in the herniated fundus and the outlet to the distal stomach is often not clear. On retroflex, the outlet is often adjacent to the gastroesophageal junction (GEJ), and with patience, the scope can usually, but not always, be manipulated such that the hernia partially detorses and the scope can be advanced to the antrum or duodenum.
The hallmark that defines a PEH on upper endoscopy is the presence of the gastric fundus above the GEJ on retroflex view (picture 1). During an esophagogastroduodenoscopy in patients with a PEH, care should be taken to avoid over-inflation of the hernia since cardiac arrest has been reported related to impaired venous return due to compression of the heart and vena cava by the over-distended intrathoracic stomach [36]. It is also recommended to use carbon dioxide rather than room air during the procedure and to evacuate the air or carbon dioxide at the completion of the upper endoscopy.
During the procedure, it is important to evaluate the esophagus for erosive esophagitis, a stricture, or the presence of a columnar-lined esophagus. Erosive esophagitis should be treated prior to surgical intervention. In patients with dysphagia, a stricture should be dilated to determine if this resolves the dysphagia. In patients with a columnar-lined esophagus, four-quadrant biopsies should be obtained to evaluate for Barrett's esophagus and possible dysplasia. (See "Barrett's esophagus: Surveillance and management".)
The stomach should be evaluated for Cameron ulcers, as these increase the risk for acute PEH-related complications and are often associated with anemia. Treatment with acid-suppression medications is the initial step, but surgical repair is indicated in these patients given evidence of better long-term control of the ulcers and any associated anemia [35]. (See "Causes of upper gastrointestinal bleeding in adults", section on 'Cameron lesions'.)
●Barium swallow – A barium swallow is an important study to delineate the presence, size, and type of a hiatal hernia (image 1). It is also useful to assess for esophageal pathology, such as a stricture. Further, a complete intrathoracic stomach is at greater risk for complications, and the type of volvulus, when present, can aid in preoperative planning since a meso-axial volvulus is a more complicated procedure and will take longer in the operating room typically than an organo-axial volvulus (picture 2).
●Esophageal manometry and pH testing (optional) – Esophageal manometry can be difficult to perform in patients with a PEH since the catheter often coils in the hernia and does not get below the diaphragm. However, since the primary reason for manometry in these patients is to evaluate esophageal body motor function, the fact that the catheter coils is not problematic and the esophageal body can be well assessed. Esophageal body function is useful for surgeons that want the option to do a Nissen rather than a partial fundoplication in patients as part of their PEH repair. If a partial fundoplication is planned, there is no need for routine manometry. Since the indication for PEH repair is the PEH, routine pH testing is not necessary.
OPERATIVE APPROACHES —
Laparoscopic transabdominal PEH repair is the preferred approach in nearly all elective primary repairs because of the significantly lower morbidity and mortality rate [31,37]. Prior to the advent of laparoscopic PEH repair, these hernias were addressed via open abdominal or transthoracic approaches [38-43]. Data indicate that the use of laparoscopy for PEH repair went from 4.9 percent up to 91.4 percent during the years 2000 to 2013 [44,45]. Increasingly PEH repairs are being performed with the aid of robotics. However, several studies have suggested that compared with a laparoscopic approach, morbidity and readmission rates are increased with the use of robotics [46,47]. Further comparison studies are awaited.
In patients with complicated reoperations or in emergency operations, there remains a role for an open approach, either transabdominal or transthoracic. There has been no randomized trial comparing results between an open and laparoscopic repair; however, a retrospective study from 2000 showed a significantly higher recurrence rate with laparoscopic compared with open elective PEH repair [39]. This high recurrence rate after laparoscopic PEH repair has been repeatedly demonstrated in the literature, including in randomized trials, and remains the Achilles' heel of the laparoscopic approach [48]. However, reoperation rates remain relatively low at under 5 percent in most series [49]. (See 'Recurrence' below.).
TRANSABDOMINAL REPAIR —
Critical steps in PEH repair are sac reduction, esophageal mobilization, assessment of esophageal length, crural closure, and fundoplication. In some patients, a Collis gastroplasty or a diaphragm relaxing incision may be necessary to address tension. An open, laparoscopic, or robotic PEH repair generally involves the same sequence of steps as detailed below.
An open transabdominal repair is typically performed via an upper midline incision. A laparoscopic or robotic repair usually requires the placement of five ports in the abdomen for the camera, surgeon's arms, and retractor instruments.
Dissection of the hiatus and hernia sac — The key step to avoid esophageal injury and to help reduce the risk of reherniation is to dissect the hernia sac from the mediastinum.
In the absence of colon or other organs in the chest (ie, a Type IV hernia), the initial step is to separate the hernia sac from the hiatus. In a Type IV hernia, as much of the colon or small bowel as possible is reduced back into the abdomen since these structures are not connected to the hernia sac in most cases.
In contrast, the hernia sac joins the esophagus at the gastroesophageal junction (GEJ) as it is part of the dilated phrenoesophageal ligament. Excessive traction on the stomach to reduce it prior to dissecting the hernia sac can lead to esophageal or gastric injury (picture 3).
During laparoscopic or robotic surgery, the capnoperitoneum fills the hernia sac like the spinnaker of a sailboat (picture 4). Dissecting the hernia sac allows the capnoperitoneum to get on the thoracic side of the hernia sac, which aids in further dissection of the sac but also decompresses the spinnaker effect and allows the stomach to be readily and safely reduced into the abdomen (picture 5).
The initial sac dissection for many surgeons is along the left crus (picture 6), since the left gastric vessels are invariably in the chest and dissection starting along the right crus may lead to injury of these vessels (picture 7). Efforts should be made to preserve the peritoneal lining of the right and left crura during this dissection as much as possible (picture 6). In the mediastinum, the hernia sac is typically bluntly dissected off the pleura and posterior mediastinal structures (picture 8) including the aorta and azygous vein (picture 9), and sharp dissection is avoided to minimize the risk of injuring these structures or the vagus nerves (picture 10). The esophagus gradually comes into view as the hernia sac is mobilized (picture 11). Further mediastinal mobilization along the esophagus should be carried up to the level of the inferior pulmonary veins (picture 10). After completing the mediastinal dissection, the excess hernia sac should be excised (picture 12) with care taken to avoid injury to the left gastric vessels, GEJ, or vagus nerves, which are typically embedded and attached to portions of the hernia sac (picture 10).
Esophageal mobilization for intra-abdominal esophageal length — Sufficient mobilization of the lower esophagus into the mediastinum ensures the return of the GEJ into the abdomen along with an adequate length of intra-abdominal esophagus (>2.5 cm). It is useful to initiate the posterior crural closure prior to assessing intra-abdominal esophageal length since patients with a PEH often have kyphosis. Posterior crural closure brings the esophagus anteriorly and into a straighter longitudinal axis. This leads to an increase in intra-abdominal esophageal length particularly in kyphotic patients.
Standard esophageal mobilization during PEH repair involves mediastinal dissection to the level of the inferior pulmonary veins. The goal is to achieve approximately 3 cm of intra-abdominal esophageal length to minimize tension on the completed repair. The technique and location for measurement of intra-abdominal length are important and vary widely. Since most recurrences occur along the left crus, it makes sense to measure from the left crus to the angle of His. This distance, without traction on the esophagus or a bougie in place, should be 2.5 to 3 cm (picture 13). If this length is less than 2.5 cm, the esophagus should be considered foreshortened and efforts to increase esophageal length are necessary. The reason for 2.5 cm is this is the length of intra-abdominal esophagus necessary for a fundoplication to be placed above the GEJ and not have tension on the repair. If no fundoplication is planned, this 2.5 cm of intra-abdominal esophageal length may not be as important, although this issue has not been well investigated.
Failure to achieve adequate esophageal length is a risk factor for hernia recurrence. When adequate intra-abdominal esophageal length cannot be achieved with normal esophageal mobilization, the options are to perform high mediastinal dissection up to the aortic arch, vagal nerve transection, or a Collis gastroplasty.
●High mediastinal dissection has been advocated as a method to achieve additional esophageal length, particularly with the aid of the wristed instruments and excellent visualization provided by robotics. However, to achieve this mobilization, the vagal branches to the pulmonary hilum must be divided up to the level of the aortic arch. This technique was routinely employed to gain esophageal length with transthoracic PEH repairs and may in part explain the excellent results reported with this approach. Achieving this dissection via the hiatus with laparoscopic or robotic surgery is challenging since the recurrent laryngeal nerve, bronchus, and pulmonary artery are all very close once the dissection proceeds above the inferior pulmonary veins. Limited reports describing the results with laparoscopic or robotic high mediastinal dissection have not conclusively shown an improvement in hernia recurrence rates compared with a standard mediastinal dissection, and at this time, the role of high mediastinal dissection is unclear [50].
●Vagal trunk transection is a proven method to add esophageal length. It avoids the need for the high mediastinal dissection and division of the vagal branches along the pulmonary hilum since the entire vagal trunk is transected along the distal esophagus. Division of one vagal trunk provides about 1 cm of esophageal length, with another 1 cm gained with division of the second trunk [51]. While division of one trunk did not lead to any significant symptoms or physiologic derangement in this study, division of both trunks led to delayed gastric emptying symptoms in most patients and should be avoided.
●Probably the most accepted and time-honored method of adding esophageal length is with a Collis gastroplasty. The original technique was described by Dr. Collis in 1957 and was accomplished via a left thoracotomy [52-54] (figure 4). The Collis procedure entails the creation of a gastric tube by vertically stapling the proximal stomach from the angle of His parallel to a 48 to 52 French bougie placed along the lesser curvature of the stomach. The newly created gastric tube becomes an extension or elongation of the native esophagus (neoesophagus) such that the new GEJ can be located intra-abdominally. The original procedure has been modified to be done transabdominally (figure 5), or minimally invasively with either thoracoscopy [55] or laparoscopy [56,57]. (See 'Transthoracic repair' below.)
The laparoscopic technique is called a wedge Collis gastroplasty because a wedge of the gastric fundus needs to be resected to permit vertical placement of the stapler parallel to the lesser curvature (figure 5). Using multiple staple firings to achieve a starfish-shaped specimen minimizes the amount of resected fundus and leaves sufficient fundus to perform a Nissen or Toupet fundoplication (figure 6).
In a nonrandomized comparative study, 50 patients underwent laparoscopic PEH repair with a bioabsorbable mesh [58]. After a median of 5.25 years, those who had a Collis gastroplasty had fewer recurrences than patients who did not have a Collis gastroplasty (7 versus 54 percent).
A key concept about Collis gastroplasty is that the Collis tube is aperistaltic, so it should be made to have a smaller diameter than the native esophagus. This will allow esophageal peristalsis to funnel the food through the Collis tube and into the stomach. The native esophagus is typically 20 mm or 60 French, and most surgeons will use a 48 to 52 French bougie to make the Collis tube. The staple line should be kept tight on the bougie to avoid a large, boggy Collis tube that does not empty well.
The second key concept is that the fundus from which the Collis tube is made has oxyntic cells and will make acid. Every effort should be made to place the fundoplication above the GEJ so that any acid produced by the Collis gastroplasty tube is below the fundoplication. In patients with a very foreshortened esophagus, the native GEJ may be at or slightly above the hiatus even after mobilization. In this situation, placing the fundoplication above the GEJ would put it into the chest, and this should be avoided. Consequently, the fundoplication is placed around the Collis tube, with some amount of Collis tube above the fundoplication. The acid produced by that portion of the Collis tube will be enough to cause erosive esophagitis in the distal esophagus since it will not be cleared and will linger on the mucosa, particularly at night. These patients need acid suppression medication to protect the distal esophageal squamous mucosa. Here again, avoiding a large, boggy Collis tube is beneficial to minimize acid production from the Collis tube. It is recommended that patients that have a Collis gastroplasty undergo upper endoscopy with consideration given to pH testing three to four months postoperatively to see if there is any esophagitis related to the Collis, and if so, start medical acid suppression therapy.
Closure of hiatal defect — A critical component of PEH repair is reconstruction of the hiatus. Since a recurrent hernia is the leading form of failure after PEH repair, careful attention should be paid to the details of crural reapproximation.
This begins with assessing the size and shape of the defect. A "V"-shaped defect will close much easier than a "D"-shaped defect, and the redundant left crus must be "reefed up" in some fashion to allow secure hiatal reconstruction [59]. The options for reefing are discussed below. (See 'Suture choice and technique' below.)
The initial crural closure sutures should be placed posterior to the esophagus, bringing the esophagus anteriorly and into a longitudinal plane. As mentioned above, it is good practice to initiate the crural closure prior to measuring intra-abdominal esophageal length since, particularly in kyphotic patients, esophageal length increases when the esophagus moves anteriorly as a consequence of posterior crural closure. (See 'Esophageal mobilization for intra-abdominal esophageal length' above.)
Suture choice and technique — A permanent suture should be used to approximate the hiatus. There is no Level 1 evidence indicating either the best suture or technique, but most commonly a braided suture is used. There are reports, particularly with robotic surgery, of using barbed monofilament sutures in a running fashion, but otherwise, most surgeons use interrupted sutures. Simple interrupted sutures or pledgeted mattress sutures are most commonly used and are started posterior to the esophagus at the base of the hiatus. An issue with permanent felt or Teflon pledgets is they are known to erode into the esophagus and stomach, and an option to avoid these materials is to use absorbable pledgets. These can be made from the mesh used for crural reinforcement. (See 'Mesh at the hiatus' below.)
When there is a "D"-shaped defect, the spacing of the sutures along the left crus should be further apart than on the right crus to allow the left crus to be "reefed up" and the redundancy addressed. On rare occasions, the upper portion of the left crus may need to be sutured to itself to eliminate redundancy.
The posterior closure continues until the reconstructed hiatus is snug around the esophagus with no significant gap (picture 14). If there is still a gap in the hiatus anteriorly or if continued posterior closure will create a "speed bump" deformity in the esophagus at the level of the hiatal closure, then an anterior stitch above the esophagus is necessary. During closure, it is important to obtain deep bites of crural tissue since it is often thin and atretic in older patients with a PEH, and the tissue tears easily. If the crural tissue appears to be tearing or there is tension approximating the crura together, it is strongly advised to use one or more tension-reducing techniques to allow a more secure hiatal reconstruction.
Addressing tension during hiatal reconstruction — Tension is always present to some degree when reconstructing the hiatus in patients with a hiatal hernia, and even more so in most patients with a large PEH. The degree of tension during crural approximation is subjective and most surgeons with experience have a sense of how much effort it takes to bring the tissues together. This subjective sense is augmented with visual clues such as evidence of the tissues tearing around the suture holes or the suture tearing out. When the suture tears out, obviously there is excessive tension, but now the crural integrity has been damaged. The goal is to address tension before the tissue tears, but also to minimize the risk of long-term failure with hernia recurrence related to unaddressed, excessive crural tension. Efforts are underway with objective measurements of crural closure tension using a tensiometer device to define a threshold for excessive tension, but no established threshold exists. Efforts to define appropriate and excessive tension would be useless if there were no options to address and reduce crural closure tension intraoperatively. This is not the case, and in fact, there are objective data confirming the role of tension-reducing techniques that all surgeons doing PEH repairs should be familiar with and able to employ intraoperatively when necessary [59].
●The first technique is to create a left capnothorax. This will place the diaphragm in a neutral position and allow less tension during crural approximation. The capnoperitoneum during minimally invasive surgery pushes the diaphragm up in an exaggerated giant exhalation, and this pulls the hiatus apart. Simply opening up the pleura just above the hiatus can address this issue. It is recommended to open both the right and left pleura to avoid unilateral atelectasis and shunting, which will cause desaturation and some difficulty with ventilation for the anesthesiologist. Bilateral capnothorax is well-tolerated and avoids the shunting issue since both lungs are now exposed to the 15 mm of capnoperitoneum used for minimally invasive surgical exposure. There is no need to place drains or chest tubes at the end of the procedure since carbon dioxide is rapidly reabsorbed. Instead, have the anesthesiologist give several large breaths once the procedure is complete, the carbon dioxide insufflation has been turned off, and the ports are being removed. A left-sided capnothorax has been shown to reduce crural approximation tension by 36 percent when measured with a tensiometer intraoperatively [59].
●If capnothorax does not lead to a sufficient decrease in crural tension, the next step is a diaphragm relaxing incision. The concept for this is similar to the relaxing incisions used in the past for inguinal hernia repair, and commonly for ventral abdominal wall hernia repairs (called a myofascial release of the external oblique or the transverse abdominus muscles). (See "Overview of component separation".)
A diaphragm relaxing incision allows primary crural closure and avoids the need for a mesh bridge across the hiatus. A mesh bridge has been associated with a high risk for mesh erosion into the esophagus and should not be used in most circumstances [60].
When a surgeon senses or visually has evidence of excessive tension during hiatal reconstruction that is not addressed by creating a left or bilateral capnothorax, a diaphragm relaxing incision is recommended. The decision for right, left, or bilateral relaxing incisions should be based on the crural anatomy and degree of tension. The right-side release is typically preferred, but if the right crus is small (less than 1.5 cm wide) or if the right release does not adequately alleviate tension, then a left or bilateral release may be necessary [61]. These relaxing incisions have proven safe and durable on follow-up [62].
•A right diaphragm relaxing incision runs parallel and 4 to 5 mm medial to the inferior vena cava, stopping below the anterior phrenic vein or the level of the apex of the hiatus (picture 15). The diaphragmatic defect created by the right relaxing incision should be closed with a 1 mm permanent polytetrafluorethylene (PTFE) or similar mesh patch sewn in with interrupted nonabsorbable sutures (picture 16). A radial incision like this on the right side is safe since the phrenic nerve is protected by the vena cava.
•In contrast, a left diaphragm relaxing incision cannot be done radially since it puts the phrenic nerve and its distribution at risk. Instead, the incision in the left diaphragm runs parallel to and about 1 to 1.5 cm inferior to the lowermost rib. Importantly, it curves medially as the incision goes posteriorly and laterally, following the course of the rib (picture 17). Generally, the incision finishes behind the spleen (picture 18). The left diaphragm relaxing incision defect is closed with a 1 to 2 mm PTFE or similar permanent mesh patch sewn in with interrupted nonabsorbable sutures. Since the left diaphragm often slides medially more than posteriorly, often only a small PTFE patch is necessary laterally while the more medial portion of the diaphragm can be repaired primarily (picture 19 and picture 20).
Fundoplication — Fundoplication is traditionally performed with PEH repair. An early proponent of just repairing the PEH without a fundoplication was Philip Allison [63]. He believed that restoring the GEJ and stomach below the diaphragm was all that was necessary to achieve a good outcome. In his 20-year follow-up report, he noted that most of his repairs were for sliding hiatal hernias, with about 9 percent being for a PEH. He noted a 49 percent recurrence rate, with many patients having recurrent symptoms. In light of this long-term report, most surgeons accepted that a fundoplication was an important adjunct to hernia repair in patients with both sliding hernia and PEH.
Subsequently, it was shown that most patients with a PEH have objective evidence of gastroesophageal reflux disease (GERD) on preoperative testing, and failure to add a fundoplication despite the absence of GERD symptoms led to a significant rate of postoperative esophagitis and objective GERD on testing [64-66]. Consequently, a fundoplication is recommended during routine PEH repair [67-69]. Some surgeons suggest that during an urgent or emergency repair a fundoplication be omitted to shorten the operation. However, the addition of a partial fundoplication adds only about 15 to 20 minutes to the operation, and no data exist that a few extra minutes in a stable patient impacts outcomes. In unstable patients or in those with an edematous fundus that precludes a fundoplication, consideration can be given to another option or ending the operation after crural closure.
In the setting of an elective repair, either a Nissen (360 degrees) or partial fundoplication can be used. (See "Surgical treatment of gastroesophageal reflux in adults", section on 'Operative techniques'.)
●In patients with Barrett's esophagus or preoperative erosive esophagitis, a Nissen fundoplication may be preferred provided esophageal function is satisfactory. If a Nissen fundoplication is planned, the patient should have preoperative manometry to exclude significant esophageal body peristaltic dysfunction, which could increase the risk for postoperative dysphagia with a complete fundoplication.
●The use of a partial fundoplication does not require preoperative manometry and is preferred in most older adult patients without severe GERD symptoms or evidence of GERD-related esophageal injury preoperatively.
Gastropexy — In an effort to minimize postoperative hernia recurrence, and to avoid a fundoplication and the risk of dysphagia, some surgeons advocate gastropexy. This practice dates back to a report by Nissen in 1956, but more recent reports provide multiple modifications of the number and location of gastropexy sutures, including suturing the entire fundus and upper greater curvature to the left diaphragm and lateral abdominal wall [29,30].
●A trial randomly assigned half of 240 patients to an anterior gastropexy after completing a PEH repair without mesh or Collis gastroplasty [70]. At one year, patients who received an anterior gastropexy had a lower PEH recurrence rate (15 versus 36 percent) and reoperation rate (2.5 versus 8.2 percent). Of these reoperations, 0.8 percent in the pexy group and 4.1 percent in the no pexy group were necessary in the first 30 days after initial PEH repair. The very high rate of overall and early reoperation in this trial raises concerns about other aspects of the PEH repair, which were not controlled at randomization.
●In a series of fundopexys compared with Toupet fundoplications in patients with a PEH, there was no difference in the operative time or frequency of postoperative dysphagia requiring dilation between groups [30]. However, the group with fundopexy had fewer reoperations and less reflux symptoms at short-term follow-up. Objective studies were not done to evaluate for GERD or hernia recurrence.
●Another study randomly assigned 40 patients to either simple cardiophrenicopexy (ie, suturing the cardia of the stomach to the diaphragm) or fundoplication during PEH repair. Those who underwent fundoplication had significantly fewer postoperative GERD symptoms at 3 and 12 months and significantly lower rates of postoperative esophagitis (17 versus 53 percent) [68]. Other postoperative complications, such as dysphagia and gas bloating, did not differ between the two groups in this study. Larger trials with objective and comparable follow-ups are awaited.
Although percutaneous gastrostomy (PEG) tubes had been used in patients with a PEH in an effort to fixate the stomach in the abdomen after PEH repair, evidence indicates that these are largely ineffective and associated with the risk of abdominal wall cellulitis. Most centers have abandoned the use of PEG tubes with the operative repair of a PEH, but PEG tubes may still be used to temporize acute gastric volvulus in poor surgical candidates. (See "Gastric volvulus in adults", section on 'Poor surgical candidates'.)
Mesh at the hiatus — Laparoscopic PEH repair is a complex procedure associated with a high objective recurrence rate in both clinical series and randomized controlled trials [48,71]. In an effort to reduce this high recurrence rate, it was logical to turn to mesh reinforcement of the hiatal closure. In theory, mesh use should prove beneficial given the years of experience and abundant evidence that mesh reduces hernia recurrence rates when used for other abdominal hernias [72,73]. (See "Hernia mesh".)
The initial randomized trials that used synthetic mesh at the hiatus suggested a benefit, but they suffered from small numbers of patients and lacked sufficient follow-up [74-76]. Subsequently, it became clear that the use of synthetic mesh at the hiatus was associated with substantial shrinkage causing severe dysphagia in patients where it was placed circumferentially around the esophagus. Further, reports of mesh erosion into the esophagus began appearing (picture 21), and studies showed that reoperations in patients with synthetic mesh at the hiatus are more complex and more likely to turn into a major resection rather than redo PEH repair [60].
An alternative to synthetic mesh is biologic mesh. Biologic mesh has been touted for its design as a collagen scaffold that allows native tissue ingrowth, and ultimately, a stronger hernia repair [77,78]. Porcine small intestine submucosa (SIS) was an early biologic mesh that was used in two randomized trials of PEH repair.
●The first showed a reduced early hernia recurrence rate in the mesh arm (9 percent with mesh versus 24 percent with primary repair) at six months but no difference at five years (54 percent versus 59 percent) [48,79].
●The second trial had three arms, two with mesh (SIS and permanent mesh) and a control group with primary repair. At six months, there was no difference in objective recurrence rates (21.8 percent for mesh versus 23 percent for primary repair) [80]. Longer (three- to five-year) follow-ups in these patients also showed no benefit for mesh in reducing hernia recurrence after PEH repair [81].
It can be concluded from these trials that either SIS mesh or the technique used in these trials (or both) failed to show a benefit for reducing hernia recurrence after PEH repair. Consequently, the question arises whether a different mesh and/or a different technique would lead to a better outcome with PEH repair. While the role of tension in hernia recurrence of all types has been clearly established over the many decades of experience with abdominal hernia repairs, neither of the two trials addressed axial tension related to a shortened esophagus or lateral tension associated with a large hiatus.
A study using a newer biosynthetic mesh that offers faster incorporation, and addressing tension with a Collis gastroplasty or diaphragmatic relaxing incision, when necessary, suggests a combination of these approaches may improve outcomes with PEH repair [58,82]. At a median of 5.25 years of follow-up, objective studies showed a recurrent hernia after primary PEH repair in 25 percent of patients. This is substantially less than the reported hernia recurrence rates at five years in other studies, reinforcing the role of tension-reducing maneuvers and biosynthetic mesh reinforcement of the crural closure during PEH repair [58].
However, the role of mesh at the hiatus remains controversial, and further studies on adjunct procedures to reduce tension when present and the use of mesh once tension has been addressed are needed. Given these issues, along with the legal concerns connected with intrabdominal synthetic mesh use, many esophageal surgeons avoid mesh at the hiatus, preferring instead to deal with a recurrent hernia if it occurs [83].
TRANSTHORACIC REPAIR —
Transthoracic PEH repair is advocated by some authorities as an alternative to transabdominal repair in patients with obesity, a very large or complex hiatal hernia (eg, Type IV with stomach, colon and small bowel in the chest), an inhospitable abdomen, or failed previous transabdominal repairs.
An open transthoracic repair permits more accurate intraoperative assessment of the esophageal length since the diaphragm is in a neutral position and the esophagus can be lifted after mobilization and reduction of the stomach into the abdomen to assess tension. When tension is recognized, a Collis gastroplasty can readily be performed. The hiatus can also be closed very securely taking excellent tissue bites, and the exposure is excellent even in obese patients [84].
The best-reported results of PEH repair come from a study of 96 transthoracic repairs. A Collis gastroplasty was used in 75 percent of patients. There were 90 patients that had follow-up at a median of 72 months, with 50 patients having more than five years of follow-up. Excellent outcomes were present in 72 of the 90 patients (80 percent), with two patients undergoing reoperation for recurrent hernia and severe gastroesophageal reflux disease (GERD) [64]. It is interesting to note that these 96 cases occurred over the 36 years from 1960 to 1996. This speaks to the dramatic increase in the prevalence of PEH that has occurred over the past several decades.
The steps of a transthoracic PEH repair include [84]:
●The hernia is typically exposed via a posterolateral left thoracotomy in the 8th or 9th intercostal space. Even if most of the hernia is located toward the right chest, a left thoracotomy is the appropriate incision since the hiatus is poorly seen via a right thoracotomy and all PEHs can be repaired from the left chest.
●The esophagus proximal to the hernia is exposed by incising the pleura along the anterior surface of the aorta and posterior to the pericardium. The dissection is continued up to the aortic arch to mobilize the esophagus with division of the vagal branches to the pulmonary hilum. The recurrent laryngeal nerve is protected at the level of the aortic arch. Next, the dissection is carried posteriorly toward the right chest, typically midway between the inferior pulmonary vein and the diaphragm in a safe area. Avoid going too far toward the spine to ensure the azygous vein is not encountered as the hernia sac is encircled. A Penrose drain is often placed around the esophagus and vagal nerves to provide traction.
●The abdominal cavity and stomach are exposed by opening the hernia sac once encircled and completely dissected off the right pleura. Any volvulus of the stomach is reduced. The hernia sac is excised exposing the gastroesophageal junction (GEJ), and proximal short gastric vessels are ligated in preparation for a fundoplication. The hiatus is dissected circumferentially with care taken to ligate "Belsey artery" when present, a small vessel sometimes found in the gastrohepatic omentum when mobilizing the right crus.
●The stomach is reduced back into the abdomen and the position of the GEJ relative to the diaphragm is assessed. If the GEJ remains at or above the hiatus, a shortened esophagus is diagnosed. Next, the stomach is brought back into the chest and posterior crural repair sutures are placed but not tied. It is much easier to safely place these sutures with the stomach still in the chest. A "Belsey spoon" aids suture placement in the right crus to avoid the vena cava. If the esophagus is short, a Collis gastroplasty is created [64,85], and if not, then the next step is the creation of a fundoplication.
●In patients with a shortened esophagus, a Collis gastroplasty is required, or else the repair is likely to fail because the excess tension exerted on the GEJ is liable to pull it back into the chest. In the two largest studies of transthoracic PEH repair, 80 and 96 percent of the patients were found to have a shortened esophagus and underwent a Collis gastroplasty [62,63]. The Collis gastroplasty was originally described as a transthoracic procedure to elongate the esophagus [53]. A 48 to 52 French bougie is passed via the mouth into the stomach and placed along the lesser curvature. A surgical stapler is then used to create an incision from the angle of His parallel to the bougie (figure 4). The stapling creates a tubularized proximal stomach that becomes a natural extension or elongation of the esophagus. Modifications of the Collis gastroplasty have been described for performance via a thoracoscopic (figure 4) or laparoscopic approach (figure 5). (See 'Esophageal mobilization for intra-abdominal esophageal length' above.)
●Either a Nissen or Belsey Mark IV fundoplication is created to minimize the risk of postoperative GERD. After the performance of the fundoplication, the stomach is reduced back into the abdomen and the previously placed crural repair sutures are tied. Often, the last one is removed to avoid over-tightening the hiatus. A well-reconstructed hiatus should feel like a tight rectal examination when the surgeon's index finger is passed alongside the esophagus through the hiatus.
●Typically, no mesh is used with a transthoracic repair to reinforce the crural closure, although pledgeted crural closure sutures are often used.
●A nasogastric tube can be placed, and the left thoracotomy is closed to complete the procedure.
POSTOPERATIVE MANAGEMENT —
Patients are typically admitted to the hospital after undergoing a PEH repair. Some surgeons maintain all patients on antiemetics for the first 24 hours postoperatively to minimize the risk of postoperative nausea or vomiting, which can disrupt the hernia repair or cause early recurrences [86].
Role of postoperative barium swallow — A barium upper gastrointestinal series study can be done on the first postoperative day to document the integrity of the repair. It is recommended early in a surgeon's experience and for all reoperations or particularly complex procedures, including after performing a Collis gastroplasty or diaphragm relaxing incision. However, with experience and the use of bioresorbable mesh, early hernia recurrence (while still in the hospital) is so rare after a first-time, standard PEH repair that routine barium studies are not necessary.
A barium swallow is recommended in any patient with symptoms or signs of an esophageal injury, in patients who deviate from a routine postoperative recovery course, and in patients with significant postoperative dysphagia. While a barium swallow can identify an esophageal leak or injury if present, up to 30 percent of leaks are missed in these studies, particularly with Gastrografin. Thin barium or computed tomography (CT) scan may provide more confidence in assessing for a leak in patients with concerning clinical features. It is important to not rule out an esophageal injury or leak based on a negative radiographic study.
Clinical signs of complications — Clinical suspicion is a critical component of caring for patients after esophageal surgery: any patient with fever, tachycardia, dyspnea, hypoxia, or a combination of these clinical features should be treated as if they have an esophageal injury until proven otherwise. Subcutaneous emphysema related to carbon dioxide insufflation during the surgical procedure is rapidly reabsorbed, and any emphysema persisting beyond 24 hours should raise concerns for an esophageal injury. Broad-spectrum antibiotics should be initiated, and the patient kept nil per os while an evaluation with thin barium swallow, CT with oral contrast, and/or an upper endoscopy are performed. Concerns that an upper endoscopy can worsen a leak are unfounded, and in fact, a small leak can be clipped closed or covered with a stent when found with upper endoscopy, making upper endoscopy an essential part of the evaluation and management of a suspected or confirmed esophageal leak.
Diet advancement — Patients recovering normally are typically started on a liquid diet that is gradually progressed over several weeks in part depending on their age, esophageal function, and if a fundoplication was performed. Patients with a longstanding PEH often have delayed gastric emptying manifest by finding food in the stomach on upper endoscopy after an appropriate preprocedure fast. Typically, patients are asymptomatic and no treatment is necessary. Mechanisms for gastroparesis in these patients include atrophic gastric musculature from chronic volvulus or vagal neurapraxia from the dissection [87]. Symptomatic patients may benefit from gastroparesis diets and medications. (See "Treatment of gastroparesis", section on 'Initial management'.)
Recovery after transthoracic repair — Since transthoracic repairs are extremely painful, it is recommended that these patients have an epidural catheter in place for optimal pain management. Recovery after a transthoracic repair is delayed related to the discomfort and potential for pulmonary complications, and most patients are hospitalized for four to seven days. Resumption of oral intake can proceed similarly to patients who had a minimally invasive approach, provided their recovery is progressing normally.
PATIENT OUTCOMES
Mortality and morbidity
●Laparoscopic repair – The overall mortality and morbidity rates associated with laparoscopic PEH repair are low. The mortality rates are under 0.5 percent at most experienced centers [14,88]. The reported major complications include pneumonia (4 percent), pulmonary embolism (3.4 percent), heart failure (2.6 percent), and postoperative leak (2.5 percent) [1].
The morbidity rates are likely higher in patients who are ≥80 years of age, those who require emergency surgery, and those who have multiple comorbid illnesses [15]. The mortality for healthy older patients undergoing elective PEH repair appears to be similar to that for younger patients, although the literature is not consistent on this issue [14]. (See 'Elective presentation' above.)
●Open transabdominal repair – In a retrospective study of 1005 open transabdominal PEH repairs, emergency procedures were associated with a much higher mortality rate compared with elective repairs (15.7 versus 2.4 percent) and were the sole predictor of mortality on multivariate analysis (odds ratio 7.1, 95% CI 1.9-26.3) [89].
●Transthoracic repair – In the two largest studies, 94 and 240 patients underwent transthoracic repair of PEH [64,85]. The postoperative mortality and morbidity rates were 2.1 and 1.7 percent, respectively.
Quality of life improvement — Regardless of approaches, PEH repairs have been shown to improve quality of life (QOL) by alleviating symptoms attributed to the hernia [18,20,39,77,90,91].
●Laparoscopic repair – A prospective study of 111 patients associated laparoscopic PEH repair with improved symptoms and better QOL at one and three years after surgery [77]. At one year, all 10 individual symptom QOL scores improved compared with baseline. At three years, the improvement in QOL scores of acid reflux, postprandial chest pain, vomiting, difficulty with swallowing, bloating/gas, shortness of breath, and condition satisfaction were sustained, and the overall QOL score was 50 percent higher than the baseline score.
Another study of over 300 patients reported that laparoscopic PEH repair resulted in significantly improved QOL as measured by the 36-Item Short Form Health Survey at both short- and long-term (two-year) intervals [92]. Additionally, Reflux Symptom Index and GERD Health-Related QOL scores improved at all postoperative time points.
●Open repair – In one study of 72 patients who underwent open transabdominal repair, symptoms such as heartburn and dysphagia were improved compared with baseline [38]. The postoperative short form-36 (SF-36) scores were higher than the general population in six of eight categories and higher than the age-matched population in eight of eight categories.
●Transthoracic repair – In the two largest studies, 94 and 240 patients underwent transthoracic repair of PEH [64,85]. At the time of follow-up (ranging from 42 to 94 months), 80 to 86 percent of patients were symptom free or reported satisfactory results from the surgery.
Recurrence — Hernia recurrence is the Achilles' heel of PEH repair, exceeding 50 percent by five years after minimally invasive PEH repair in randomized trials and well-done single-center studies [48]. This rate is significantly higher compared with results from the open repair era [39]. Reasons likely include fewer adhesions with the minimally invasive repair, difficulty assessing esophageal length and crural tension given altered haptics and the artificially elevated diaphragms with capnoperitoneum during minimally invasive repairs, and less esophageal mobilization, particularly when compared with open transthoracic repairs.
Hernia recurrence is associated with a decrease in QOL and more symptoms compared with patients without recurrence. However, only about 5 percent of recurrences are considered severe enough to warrant reoperation [49]. The need for reoperation is higher in early and larger hernia recurrences. Reoperation for a recurrent PEH should only be undertaken at experienced centers since these operations have been shown to be more complicated than primary repairs and associated with a higher risk for complications [93].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hiatal hernia".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Hiatal hernia (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Timing of paraesophageal hernia repair – For healthy patients with a paraesophageal hernia (PEH), we advocate early surgical repair rather than watchful waiting. Contemporary data on perisurgical risk versus risks of disease progression suggest benefit for most patients, even those with minimal symptoms, age over 80, and significant comorbidities. Early surgical repair staves off complications such as gastric volvulus or strangulation, which require emergency surgical repair with increased morbidity and mortality. (See 'Elective versus urgent surgical repair' above.)
●Symptoms of paraesophageal hernia – PEHs are most associated with chest fullness or discomfort, episodic epigastric or chest pain, or dyspnea, particularly after meals. Less common symptoms include heartburn or regurgitation, dysphagia, and anemia (with or without Cameron lesions). (See 'Patient history' above.)
●Preoperative evaluation – Prior to surgical repair of a PEH, all patients should undergo endoscopic evaluation of the upper digestive tract and a barium swallow study. A manometry study is optional and only necessary if a complete fundoplication is planned. (See 'Testing' above.)
●Operative approaches – For most elective PEH repairs, we suggest a minimally invasive, transabdominal approach, either laparoscopic or robotic (Grade 1B). Open approaches, either transabdominal or transthoracic, are reserved for highly selected, complex patients, given the increase in complications and length of recovery associated with an open operation. (See 'Operative approaches' above.)
●Critical steps in an operation – Critical steps in PEH repair are sac reduction, esophageal mobilization, assessment of esophageal length, crural closure, and fundoplication. In some patients, a Collis gastroplasty or a diaphragm relaxing incision may be necessary to address tension, and surgeons performing PEH repairs should be comfortable with these adjunct procedures to minimize the risk of recurrence. (See 'Transabdominal repair' above and 'Transthoracic repair' above.)
●Postoperative management – A barium upper gastrointestinal series study can be performed on the first postoperative day early in a surgeon's experience, for all reoperations, and for particularly complex procedures, including after performing a Collis gastroplasty or diaphragm relaxing incision. (See 'Role of postoperative barium swallow' above.)
A barium swallow is also required whenever any patient shows symptoms or signs of an esophageal injury, deviates from a routine postoperative recovery course, or complains of significant postoperative dysphagia. However, it is important not to exclude an esophageal injury or leak based on a negative radiographic study when there are clinical signs of fever, tachycardia, dyspnea, hypoxia, or subcutaneous emphysema. Surgical re-exploration is required when a leak is suspected radiographically or clinically. (See 'Clinical signs of complications' above.)
●Patient outcomes – When performed by experienced surgeons, elective PEH repairs are safe and lead to improved quality of life (QOL) and reduced risk of serious PEH-related complications that might necessitate emergency surgical intervention. (See 'Patient outcomes' above.)
●Recurrences – The recurrence rate of laparoscopic PEH repair is higher than that of open repairs. However, <5 percent of recurrences are severe enough to warrant reoperation. Reoperation is reserved for symptomatic patients and should only be performed by highly experienced surgeons due to its complexity. (See 'Recurrence' above.)
