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Hiatal hernia — Clinical Guidelines

Overview

Hiatal hernia involves the protrusion of abdominal contents through the diaphragmatic hiatus into the thoracic cavity, commonly affecting the stomach. Paraesophageal hernias, a subtype, can progress to complications like obstruction or ischemia, necessitating surgical intervention 1.

Diagnosis

Key Diagnostic Criteria: Symptoms include heartburn, regurgitation, and dysphagia; imaging (barium swallow, CT) often confirms diagnosis 8 10.

Recommended Tests: Barium swallow useful for visualizing herniation; CT scans provide detailed anatomical assessment 8 10.

Grading: No standardized grading system universally accepted; clinical presentation and imaging findings guide severity assessment 1.

Management

First-Line Treatments: Medical management with proton pump inhibitors (PPIs) for symptom control in asymptomatic or minimally symptomatic cases 1.

Surgical Interventions:

- Elective Repair: Fundoplication or gastric fixation; outcomes vary by urgency 3. - Emergent Repair: Fundoplication preferred for better clinical outcomes compared to gastric fixation in emergency settings 3.

Adjunctive Treatments:

- Pain Management: Instillation of local anesthetics (e.g., 0.25% bupivacaine) or postoperative back massagers to reduce postoperative shoulder pain 2. - Mesh Use: Consideration for large hiatal hernias to reduce recurrence rates, though practice varies widely among surgeons 6.

Special Populations

Elderly: Higher risk of complications; careful risk-benefit assessment needed for surgical intervention 1 5.

Pediatrics: Younger siblings of affected children have a higher incidence of hiatal hernia, particularly with symptoms like vomiting and regurgitation 8.

Comorbidities: Presence of comorbidities may influence surgical approach and outcomes; individualized management is crucial 1 3.

Key Recommendations

Consider elective repair for symptomatic paraesophageal hernias to prevent complications (Evidence: Moderate 1).

Fundoplication is associated with better 30-day clinical outcomes compared to gastric fixation in emergency hiatal hernia repairs (Evidence: Moderate 3).

Use of local anesthetics for postoperative pain management can reduce opioid use and pain severity post-LARS (Evidence: Moderate 2).

Mesh reinforcement should be considered for large hiatal hernias to potentially reduce recurrence rates, though practice varies (Evidence: Weak 6).

References

1 Crnkovic CM, Slaughter JC, Howell D, Plymale MA, Davenport DL, Inabnet WB et al.. Paraesophageal Hernia Repair Outcomes in Elective, Urgent, and Emergent Patient Populations. Journal of the American College of Surgeons 2026. link 2 Mittal SK, Latorre-Rodríguez AR, Bremner RM. Shoulder pain after laparoscopic antireflux surgery: a single-center, randomized, open-label trial. Surgical endoscopy 2025. link 3 Srikrishnaraj D, Hawel J, Schlachta CM, Elnahas A. Fundoplication vs. gastric fixation for the management of emergency hiatal hernia repairs: a retrospective cohort study. Surgical endoscopy 2024. link 4 Liu Z, He L, Jiao Y, Xu Z, Suo J. An extremely rare case of lesser omental hernia in an elderly female patient following total colectomy. BMC surgery 2020. link 5 Ceccarelli G, Pasculli A, Bugiantella W, De Rosa M, Catena F, Rondelli F et al.. Minimally invasive laparoscopic and robot-assisted emergency treatment of strangulated giant hiatal hernias: report of five cases and literature review. World journal of emergency surgery : WJES 2020. link 6 Frantzides CT, Carlson MA, Loizides S, Papafili A, Luu M, Roberts J et al.. Hiatal hernia repair with mesh: a survey of SAGES members. Surgical endoscopy 2010. link 7 Braunstein JT, Crues JV. Magnetic resonance imaging of hereditary hernias of the peroneus longus muscle. Skeletal radiology 1995. link 8 Thomas PS, Carré IJ. Findings on barium swallow in younger siblings of children with hiatal hernia (partial thoracic stomach). Journal of pediatric gastroenterology and nutrition 1991. link 9 Childress MH, Martel W. Radiologic appearance of the Collis-Belsey fundoplication. Journal of the Canadian Association of Radiologists 1977. link 10 Van Kuyk PJ. Diagnostic radiology in fundoplication according to Nissen. Radiologia clinica 1976. link 11 Edwards MH. Selective vagotomy of the canine oesophagus--a model for the treatment of hiatal hernia. Thorax 1976. link

Hiatal hernia