Hiatal hernias are classified as types I–IV, with types II–IV representing forms of paraesophageal hernia (PEH) (FIGURE 1). Patients with PEH may develop gastric volvulus, which is classified based on the axis of rotation (FIGURE 2). Organoaxial volvulus is the most common type, and it accounts for almost all cases of acute gastric volvulus (FIGURE 2A). This involves rotation of the stomach around the anatomic (longitudinal) axis, represented as a line drawn from the cardia to the pylorus, frequently resulting in gastric strangulation. In mesoentericoaxial volvulus, the antrum of the stomach rotates anteriorly and superiorly around a transverse axis that extends from the middle of the lesser curvature to the middle of the greater curvature (FIGURE 2B). The rotation is typically incomplete and results in intermittent gastric obstruction rather than acute strangulation.
Approximately half of all PEHs are clinically silent and become apparent on imaging studies obtained for another reason. Symptoms are caused either by obstruction of the stomach or distal esophagus or by gastroesophageal reflux related to lower esophageal sphincter (LES) incompetence. Large PEHs most commonly present with symptoms of gastric obstruction, including epigastric or chest pain, dysphagia, emesis, and postprandial fullness. A third of patients present with iron-deficiency anemia secondary to chronic blood loss from erosions of the gastric mucosa caused by repeated movement across the hiatus.
Patients who present with acute gastric volvulus require urgent repair to prevent gastric necrosis. Nasogastric decompression prior to surgery may relieve the acute symptoms of gastric obstruction and allow the repair to be performed in an urgent, rather than emergent, setting. The current recommendation for patients presenting for elective evaluation of PEH is that all type II hernias should be repaired because of the risk of gastric volvulus, and consideration should be given to type III hernias regardless of symptoms in medically fit patients. Watchful waiting represents a reasonable course of action for patients with high surgical risk and those with truly asymptomatic PEHs.
A full general medical evaluation is performed, and the usual preanesthesia testing is obtained. Esophageal function studies such as manometry and video esophagography are necessary to plan for a full or partial fundoplication and to detect underlying esophageal dysmotility. Special emphasis is placed on the pulmonary workup. Pulmonary function studies are needed in high-risk patients, especially if recurrent episodes of aspiration pneumonia or asthma have occurred. Antacids, acid blockers, and proton pump inhibitors are continued. Perioperative antibiotic coverage should be used.
General anesthesia with endotracheal intubation is used. An orogastric tube is placed for gastric decompression.
For laparoscopic repair, the patient is placed in the supine split-leg or low lithotomy position with the arms out on arm boards or tucked in at the sides (FIGURE ...