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Paraesophageal Hiatal Hernia

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• The esophageal hiatus is formed by the right crus and little or no left crus.

• The phrenoesophageal ligament, which holds the distal esophagus in place is formed by fusion by endothoracic and endoabdominal fascia at the esophageal hiatus.

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CLASSIFICATION

• There are 4 types of hiatal hernias.

• The sliding hernia or type I is the most common.

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Type I Hiatal Hernia

• The E-C junction moves through the hiatus to the visceral mediastinum.

• Increased abdominal pressure( pregnancy, obesity, or vomiting ) and vigorous esophageal contraction may contribute the development of the hernia.

• G-E reflux and esophagitis may occur due to loss of tone of the LES.

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Type II Hiatal Hernia

• It is uncommon.

• The phrenoesophageal membrane is not weakened diffusely but focally.

• The gastric fundus protrudes through the hiatus.

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Type III Hiatal Hernia

• It is combined with type I and type II.

• It is frequently present when a type II hiatal hernia have been present for many years.

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Type IV Hiatal Hernia

• It refers hernia of organs other than the stomach.

• The T-colon and the omentum are the most common involved.

• The spleen and the small intestine may be involved.

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ANATOMY AND PHYSIOLOGY

• In a true paraesophageal hiatal hernia, the lower esophagus and the cardia remain fixed below the diaphragm in the posterior aspect of the diaphragmatic hiatus.

• The herniated organs are covered with a layer of the peritoneum that forms a true hernia sac, unlike the type I hiatal hernia, in which the stomach forms the posterior wall of hernia sac.

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ANATOMY AND PHYSIOLOGY

• Complications are bleeding, incarceration, volvulus, obstruction, strangulation and perforation.

• Gastritis and ulceration have been seen. The ulcer are the result of poor gastric emptying and torsion of the gastric wall.

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SYMPTOMS

• Many type I and type II hernia have few or no symptoms.

• Bleeding results from gastritis and ulcer can induce IDA, resulting in fatigue and exertional dyspnea.

• Postprandial discomfort may occur. The substernal fullness is often mistaken MI.

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SYMPTOMS

• In type II hernia, G-E reflux and true dysphagia is uncommon.

• If vovulus occurs, severe pain and pressure in the chest or epigastic region.

• Fever, hypovolemic shock will be present if volvulus progresses and strangulation occurs. In this situation, mortality rate is 50%.

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DIAGNOSIS

• The diagnosis is suspected first on the CXR.• The most common finding is retrocardiac b

ubble with or without air-fluid level.• In a giant hiatal hernia, the herniated organ

may be found in the right thoracic cavity.• D.D: mediastinal cyst or abscess, dilated ob

structed esophagus, as end stage of achalasia.

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DIAGNOSIS

• The barium study of the UGI confirms the diagnosis.

• Endoscopy and esophageal function test can detect the function of LES.

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THERAPY

• There is no accepted medical treatment for hiatal hernia.

• Surgery is indicated to prevent complications.

• In type II hernia, if gastric volvulus or obstruction is present without toxic signs, NG decompression must be performed. The surgery is scheduled.

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Operative Approaches

• The operation or operative approach is controversial.

• The principles of operation is reduction of the hernia, resection of the hernia sac and closure of the defect.

• It is easy to do intrathoracic dissection via thoracotomy.

• However, transthoracic reduction may lead to volvulus of the gastric body.

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Operative Approaches

• Abdominal approach is also suggested.• Additional procedures can be done, such as

gastrotomy, which obviates the NG tube and decreases the risk of recurrent volvulus.

• Abdomional approach is difficult to do in type III hiatal hernia with G-E reflux and a foreshortened esophagus.

• Laparoscopic repair is also advocated.

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Should a Antireflux Procedure Be Induced?

• It is controversial.

• It is indicated in patients with esophagitis by symptoms and endoscopy, with a hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring.

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Operative Technique: Conventional Abdominal Approach

• The author prefers abdominal approach via upper midline incision.

• In type II hernia, the E-C junction is still in the abdomen, bounded posteriorly with a fibrous band. It is careful not to take down the attachment.

• Dissection is done on the lower 4 to 8 cm of the esophagus.

• The repair is done with nonabsorbable O sutures.

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Operative Technique: Conventional Abdominal Approach

• Antireflux procedure is done when significant reflux esophagitis is present.

• A loose Nissen fundoplication is suggested by authors.

• If no fundoplication is performed then the stomach can be fixed by two methods: Hill suture plication and Stamm gastrostomy.

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Operative Technique: Conventional Abdominal Approach

• Hill suture plication: 3 interrupted nonabsorbable sutures between lesser curve of the stomach and preaortic fascia

• Stamm gastrostomy: 2 functions

1. It eliminates the need of NG tube.

2. It fixes the stomach to the abdominal wall

and to prevent volvulus.

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Operative Technique: Laparoscopic Approach

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Operative Morbidity and Mortality

• The operative mortality is less than 0.5%.• If gasric volvulus occurs, the operative mort

ality is up to 14%.• Pulmonary complication may be seen in pat

ients with aspiration resulting from volvulus or obstruction.

• Complication of gastric stasis may result from edema of the released gastric segment.

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Operative Morbidity and Mortality

• Other complications include gastric perforation, gastric bleeding, slipped Nissen fundoplication, small bowel obstruction and atelectasis.

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RESULTS

• Long-term results are excellent.

• Simultaneous antireflux procedure is ineffective prophylaxis against recurrent herniation resultant G-E reflux.

• The long-term result after laparoscopic repair is unknown.

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Thank You!