Paraesophageal hernias comprise approximately 5% to 15% of all hiatal hernias and are challenging hernias to repair. Most commonly, these occur in patients age >50 to 60 years. The natural history of paraesophageal hernia repair has not been systematically studied, but, in general, many patients present with a longstanding history of hiatal hernia. Therefore, it’s likely that these progressively enlarge over time. While they can be asymptomatic, some patients present with acute gastric outlet obstruction and/or gastric ischemia that requires emergency surgical intervention. In this chapter, the clinical presentation, diagnostic evaluation, and surgical technical aspects and resultant outcomes of paraesophageal hernia repair will be presented.
The classification of hiatal hernia is illustrated by the radiographic studies shown in Figure 24-1. Type I hernias are sliding hiatal hernias defined by the location of the gastroesophageal (GE) junction above the diaphragm. Types II, III, and IV are different types of paraesophageal hernias. In type II paraesophageal hernias (PEHs), the GE junction is in a normal position and a portion of the upper stomach, usually the fundus, is herniated alongside the esophagus through the hiatus. Type II PEHs account for a relatively small percentage of cases. The most common type of PEH is type III, in which there is a combined sliding and paraesophageal component. These hernias can be quite large, with most of the stomach, if not the entire stomach, in the chest and associated volvulus. Type IV PEHs are those in which some other organ besides the stomach is herniated into the chest, most commonly the colon, but also possibly the small bowel, pancreas, and duodenum.
Barium swallow that illustrates the 4 types of hiatal hernias. A. Type I sliding hernia. B. Type II paraesophageal hernia (PEH). C. Type III PEH. D. Type IV PEH with intrathoracic stomach; note the bowel gas in the left chest, which is due to herniated colon.
Because of the large size of the defect and extent of herniation, the stomach may undergo rotation within the hernia sac. Most commonly, this consists of organoaxial volvulus in which the stomach rotates along the axis of the organ. This type of volvulus results in the greater curvature being flipped upward and at a higher position in the mediastinum than the lesser curvature (Fig. 24-2A). The stomach can also rotate along the axis of its mesentery (mesoaxial volvulus). Mesoaxial volvulus is associated with a higher risk of gastric ischemia because of the twisting of the mesentery, which can compromise venous return and gastric blood flow (Fig. 24-2B).