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385
Hiatal Hernias
Contents
Chapter 37 General Issues ofHiatal Hernias–387
Burkhard H. A. von Rahden, Sumeet K. Mittal,
and Ellen Morrow
Chapter 38 Techniques ofHiatal Hernia Repair–393
Beat Müller-Stich, Philip C. Müller,
Rudoph Pointner, Stavros A. Antoniou,
Burkhard H. A. von Rahden, and Sumeet K. Mittal
Chapter 39 Mesh Technology inHiatal Hernia–409
Ferdinand Köckerling, Beat Müller-Stich,
and Bruce Ramshaw
III
Chapter 40 Complications ofHiatal Hernia Repair
andPrevention–415
Jelmer E. Oor, Ferdinand Köckerling,
Rajesh Khullar, and Eric J. Hazebroek
Chapter 41 Complex Hiatal Hernias–421
Dirk Weyhe and Pradeep Chowbey
Chapter 42 Hiatal Hernia RepairinDicult Pathologic-
Anatomic Situations attheHiatus–433
Pradeep Chowbey, Alice Chung, and Ellen Morrow
Chapter 43 Comparisons ofMethods at Hiatal Hernia
Repair–439
Sumeet K. Mittal
Chapter 44 New Technologies inHiatal Hernia Repair:
Robotics, Single Port–447
and Sujith Wijerathne
Chapter 45 Education andLearning inHiatal Hernia
Repair–457
Davide Lomanto and Hrishikesh P. Salgaonkar
Chapter 46 Anesthesiologic Aspects ofLaparoscopic
Hernia Repair–465
Claudia Hafner-Chvojka and Wilfried Junginger
387
General Issues
ofHiatal Hernias
BurkhardH. A.von Rahden, SumeetK.Mittal, andEllenMorrow
37.1 Anatomy oftheEsophagus Hiatus:
What Is Important forHiatal
Hernia Surgery? – 388
37.2 Pathophysiology ofHerniation
andDiagnostics – 389
37.3 Classication – 389
37.4 Diagnostic Work-Up – 390
37
37.5 Limitations andIndications for
Laparoscopic Repair: Reux Disease
andParaesophageal Hernias – 390
37.6 Perioperative Management – 391
References – 391
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_37
388
B. H. A. von Rahden et al.
37
37.1 Anatomy oftheEsophagus
Hiatus: What Is Important
forHiatal Hernia Surgery?
e esophagogastric junction and the esophageal
hiatus represent an anatomic unit which functionally resembles the lower esophageal sphincter
(LES) [1, 2]. Furthermore, the LES must also be
regarded as one functional unit together with the
tubular esophagus and the upper esophageal
sphincter (UES). Acknowledgment of these functional units seems of crucial importance for hiatal
hernia surgery, due to the important eects on
esophageal function, i.e., esophageal emptying
and antireux mechanisms.
! Note: Hiatal hernia surgery is always also
functional esophageal surgery!
e UES is located at the level of the cricoid and
is resembled by the cricopharyngeal muscle.
Aboral from this muscle, the tubular esophagus originates. e esophageal wall consists
of an inner circular muscle layer and an outer
longitudinal muscle layer and the esophageal
mucosa. e architecture of the musculature at
the esophagogastric junction is more complex,
with the semicircular clasps and the gastric sling
bers being of major importance for constitution
of the LES [1] (see gure “Abb. 24.3 Architektur
des tubulären Ösophagus” from Siewert, Praxis
der Viszeralchirurgie, Bd. 2). e surrounding
muscular structures of the diaphragm, i.e., le
and right diaphragmatic crus, also contribute to
this complex sphincter apparatus and the lower
esophageal sphincter pressure.
e esophageal hiatus is an anatomic gap
within the posterior part of the diaphragm. It consists of the right diaphragmatic crus, an anterior
commissure of the diaphragmatic crura, and the
le diaphragmatic crus. rough this gap, the
esophagus enters the abdominal cavity and the
thoracic esophagus becomes the abdominal
esophagus. For surgery of the esophagogastric
junction, it is of utmost importance to note that
2–3cm of the esophagus belongs to the abdomen,
and the major aim of any hiatal hernia operation
is to restore this situation. Under the circumstances of type III hiatal hernias, the esophagus is
usually retracted into the mediastinum, due to the
displaced esophagogastric junction (see . 37.3
Classication).
! Note: The major aim of any hiatal hernia
operation is to restore an adequate length
of the abdominal esophagus!
Immediately behind the esophageal hiatus, the
aortic hiatus is localized, where the aorta enters
the retroperitoneum. Under the pathophysiologic
conditions of large hiatal hernias, both openings– esophageal and aortic hiatus– are sometimes “unied” and form a common hiatus.
Preservation of both – anterior and posterior– vagal nerves during hiatal hernia surgery is
crucial for gastrointestinal function. e vagal
nerves accompany the esophagus closely at the
anterior and posterior esophageal wall. It may not
always be necessary to visualize the vagal nerves
during hiatal hernia surgery, which can be dicult in obese patients with large hernias, but the
surgeon must be aware of their localization and
leave them intact.
More controversial than preservation of the
trunks of the vagal nerves is whether its hepatic
branches must be preserved (see 7 Chap. 4). e
hepatic branches originate from the anterior
vagal nerve at the level of the esophagogastric
junction and run toward the liver through the
condense part of the lesser omentum. At the
level of the liver, the pyloric branches originate
from these hepatic branches and go through the
hepatoduodenal ligament to reach the pylorus.
ese branches are deemed involved in relaxation of the pylorus and thereby gastric emptying.
Prominent diaphragmatic veins close to the
hiatus must be avoided during dissection and crural repair. Injury of one of these veins can result in
signicant bleeding, due to their communication/
drainage to the le liver vein and the inferior caval
vein.
Aberrant/accessory le hepatic arteries, originating from the le gastric artery, occur in about
12% of patients [3]. ese arteries accompany the
aforementioned hepatic branches of the vagal
nerve within the condense part of the lesser
omentum. It is advisable to preserve these structures during hiatal hernia surgery.
e posterior parts of the gastric fundus are
attached to the le diaphragmatic crus. e
short gastric vessels, located within the gastrosplenic ligament, enter the stomach at the
greater curve. Creation of a tension-free fundoplication oen makes partial division of the
General Issues ofHiatal Hernias
389
37
short gastric vessels necessary. is is usually
possible without negative side eects for the
stomach as well as the spleen: the stomach has a
very good blood supply through le and right
gastroepiploic arteries and le and (to a lesser
degree) right gastric arteries. e spleen may
show (functionally irrelevant) small defects of
blood supply aer division of the short gastric
vessels.
e anatomy of the le hepatic lobe and its
tendinous attachments to the diaphragm is also
important for hiatal hernia surgery, because
its retraction (using a special liver retractor) is
always necessary to expose the hiatus region.
Furthermore, in some cases – especially when
mesh augmentation is intended– mobilization of
the le liver lobe may be necessary.
Further important structures to know are location of the pleura and lungs. Especially in large
hiatal hernias, the pleura is oen closely colocalized or even attached to the hernia sac. One
should always try to lateralize the pleura by gentle
blunt dissection, to avoid pleural opening, which is
associated with the risk for tension pneumothorax.
37.2 Pathophysiology
ofHerniation andDiagnostics
In hiatal hernias, the widened esophageal hiatus
is the hernia orice through which the esophagogastric junction/stomach herniates into the
mediastinum. In large hernias, this hernia orice has a clearly visible ring shape through
which a clearly visible hernia sac protrudes into
the lower mediastinum. Little is known about
the exact mechanism how hiatal hernias originate. Hiatal hernia formation is presumably a
multifactorial process, which is incompletely
understood.
ree major pathogenetic “pathways” can be
derived from the relatively scarce literature, which
force the esophagogastric junction/stomach
upward into the thorax [4]:
1. Increased intra-abdominal pressure
2. Widening of the diaphragmatic hiatus due to
congenital or acquired changes in the crural
muscles or the connective tissue of the
diaphragm
3. Esophageal shortening
e latter point “esophageal shortening” is a matter of strong controversial debate. Proponents
of the view supporting the existence of “short
esophagus” suggest that an esophageal lengthening procedure is required (Collis gastroplasty)
under these circumstances. Opponents who
don’t believe in “short esophagus” think that an
adequate length of the abdominal esophagus can
always be achieved with adequate mediastinal
type II dissection (see chapter “surgical technique”)
37.3 Classication
A very simple and commonly used classication
system for hiatal hernias– based on morphologic
and pathophysiologic criteria – distinguishes
type I, II, III, and sometimes IV hernias: Type I
hernias are axial hernias, in which the anatomic
cardia/esophagogastric junction “slides” along the
esophagogastric axis through the enlarged hiatal
gap toward the mediastinum. erefore these
hernias are also addressed as “sliding hernias”,
meaning that they are usually not xed. Type II
hernias are paraesophageal hernias, in which the
anatomic cardia remains in the infradiaphragmatic position, but the gastric fundus herniates
into the mediastinum and stays in a paraesophageal position. is type of hiatal hernia is very
rare, because paraesophageal herniation usually
goes ahead with some degree of axial herniation
as well, which represents (mixed-type) type III
hernias. e maximum variant of type II/III hernias is the upside-down stomach. More complex
hernias, including other organs (colon, spleen,
liver, pancreas), are sometimes addressed as
type IV hernia.
Although this classication appears almost
generally accepted, distinction of these hernia
types bears some diculties in clinical practice as
all diagnostic tools (esophagogastroscopy, barium
swallow, cross-sectional imaging) and even intraoperative assessment may be imprecise to some
degree (e.g., Linke etal. [5]). However, this is not
important, because surgical management is on
principle the same for all hernia types. Laparoscopic
repair is almost always feasible and superior to
open surgery in almost all situations. is is even
the case for complex (type IV) hernias. A laparoscopic approach is almost always adequate.
390
B. H. A. von Rahden et al.
37
37.4 Diagnostic Work-Up
e basic tool for diagnostic work-up of hiatal
hernias is endoscopy. Usually, the rst suspicion
for hiatal hernia is raised based on this investigation, which always includes inspection of the
esophagogastric junction in forward as well as
retroexed view. Endoscopic grading of hiatal
hernias should be performed according to the Hill
classication [6].
e major aim of endoscopic examination is
exclusion of other pathologies (especially malignancies) and characterization of hernia size and
type. For classication of endoscopic appearance of hiatal hernias, the Hill classication is
established [6, 7]. Other important information
obtained from endoscopic examination are prevalence of esophagitis (erosive GERD) – which
should be graded with one of the available classications (e.g., L.A. grades)– and the columnarlined esophagus with orally transposed Z-line and
intestinal metaplasia (Barrett’s esophagus; here
grading with the Prague C & M classication is
recommendable [8] and manageable according
to current guidelines [9, 10]). Although Barrett’s
esophagus is no longer a contraindication against
hiatal hernia surgery/fundoplication anymore,
it is important to note that the indication for
surgery should aim at symptom control and not
prevention of Barrett progression/malignant progression in general.
Cross-sectional imaging with computed tomography (CT) or magnetic resonance imaging (MRI)
is also advisable in advance of performing hiatal
hernia repair. e obtained morphologic information can be helpful for the procedure, with
respect to anatomic and pathoanatomic structures (see
imaging tool which can be used in imaging of hiatal hernias. Although esophagography can nicely
depict especially large hiatal hernias, which are
xed to the mediastinum, the value of this investigation has been called into question [5].
Esophagography does rarely deliver important
additional information and can be omitted from
diagnostic work-up prior to hiatal hernia surgery,
although most guidelines do still recommend its
use.
manometry and reux testing is required when-
7 Sect. 37.1).
Esophagography (barium swallow) is another
Gastroesophageal function testing with
ever functional esophageal surgery is recommended prior to operations for GERD with hiatal
type I hernias. In contrast, catheters for function
testing are dicult or impossible in large hiatal
(type II/III) hernias. erefore, hiatal hernia
operations are usually performed without prior
function testing in these patients.
Manometry should be performed prior to
antireux surgery/type I hiatal hernias whenever
possible. e major goal is exclusion of achalasia.
is is important, because failure to diagnose
achalasia prior to fundoplication is a catastrophe
for the patient. Manometry is crucial in this
respect, because sensitivity of symptoms and
esophagogastroscopy appears too low to safely
exclude achalasia. One other reason to use
manometry is proper positioning of the pHmetry/impedance catheter by identication of the
lower esophageal sphincter.
Reux testing is necessary whenever the indication for surgery is gastroesophageal reux,
because symptoms, PPI test, and endoscopic ndings are usually not sensitive enough as proof.
Which kind of function testing is performed may
be irrelevant, but multichannel impedance-pH
testing (o PPI) may have the best diagnostic
yield and allows identication of patients with
acidic as well as weakly acidic reux.
37.5 Limitations andIndications for
Laparoscopic Repair: Reux
Disease andParaesophageal
Hernias
All paraesophageal/mixed-type hiatal hernias
(types II, III, and IV; see 7 Sect. 37.3 Classication)
are obligatory indications for surgery! Reasons for
this obligatory surgical indication are:
1. e risk for incarceration
2. e tendency of hiatal hernias to increase in
size
3. e potentially increasing diculty of
surgical repair with increasing size
4. e high mortality of an emergency opera-
tion in case of incarceration
However, some controversial academic debate has
challenged this general recommendation for surgery [11–13]. It has been suggested that the aforementioned risks might be lower than previously
General Issues ofHiatal Hernias
391
37
thought and a more selective approach might be
justied, with an observational strategy in asymptomatic or minimally symptomatic patients.
However, most patients harboring type II/III hiatal hernias have symptoms, and asymptomatic
and minimally symptomatic patients are very
rare.
! Note: Type II/III hernias are an obligatory
indication for surgery!
Type I hiatal hernias are no indication for surgery.
However, they are addressed surgically during
antireux surgery for gastroesophageal reux disease, where the indication is independent from
prevalence of hernia (and fundoplication works
also in patients who have no hiatal hernia). e
indications for surgery in this setting requires a:
1. Proven gastroesophageal reux disease
(GERD)
2. High suer score
3. Failure of conservative treatment (PPI,
lifestyle adjustment, dietary measures)
Proof of GERD means that reux has been demonstrated functionally by means of reux testing
(e.g., pH-metry/impedance). e sensitivity of
morphologic criteria, i.e., reux esophagitis,
appears too low, so that function testing must be
recommended also in patients with erosive
GERD.
37.6 Perioperative Management
Apart from the aforementioned diagnostic work up, no specic perioperative management is
required for hiatal hernia surgery.
Patients need to sign informed consent aer
being informed about general and specic surgical risks. Especially the risk for recurrence must
be addressed prior to all hiatal hernia operations.
Furthermore some controversial issues regarding
the choice of surgical procedure should be discussed with the patient, especially the potentially
advisable mesh reinforcement aer crural repair–
a decision usually drawn intraoperatively based
on measurement of the size of the hiatal hernia
gap. e otherwise high recurrence rate on the
one hand and the potential associated risks (mesh
migration, penetration, perforation, etc.) should
be highlighted.
References
1. Korn O, Stein HJ, Richter TH, Liebermann-Meert
D.Gastroesophageal sphincter: a model. Dis Esophagus. 1997;10:105–9.
2. Liebermann-Meert D, Allgöwer M, Schmid P, Blum
AL. Muscular equivalent of the lower esophageal
sphincter. Gastroenterology. 1979;76:31–8.
3. Hiatt JR, Gabbay J, Busuttil RW.Surgical anatomy of the
hepatic arteries in 1000 cases. Ann Surg. 1994;220:50–2.
4. Weber C, Davis CS, Shankaran V, Fisichella PM. Hiatal
hernias: a review of the pathophysiologic theories and
implication for research. Surg Endosc. 2011;25:3149–53.
5. Linke GR, Borovicka J, Schneider P, Zerz A, Warschkow
R, Lange J, Müller-Stich BP.Is a barium swallow complementary to endoscopy essential in the preoperative assessment of laparoscopic antireux and hiatal
hernia surgery? Surg Endosc. 2008;22:96–100.
6. Hansdotter I, Björ O, Andreasson A, Agreus L, Hellström P, Forsberg A, Talley NJ, Vieth M, Wallner B.Hill
classication is superior to the axial length of a hiatal
hernia for assessment of the mechanical anti-reux
barrier at the gastroesophageal junction. Endosc Int
Open. 2016;4:E311–7.
7. Jobe BA, Kahrilas PJ, Vernon AH, Sandone C, Gopal DV,
Swanstrom LL, Aye RW, Hill LD, Hunter JG.Endoscopic
appraisal of the gastroesophageal valve after antireux surgery. Am J Gastroenterol. 2004;99:233–43.
8. Alvarez-Herrero L, Curvers WL, van Vilsteren FG, Wolfsen H, Ragunath K, Wong Kee Song LM, Mallant- Hent
RC, van Oijen A, Scholten P, Schoon EJ, Schenk EB,
Weusten BL, Bergman JG. Validation of the Prague
C&M classication of Barrett's esophagus in clinical
practice. Endoscopy. 2013;45:876–82.
9. American Gastroenterological Association, Spechler
SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ.American Gastroenterological Association medical position
statement on the management of Barrett's esophagus. Gastroenterology. 2011;140:1084–91.
10. Wang KK, Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology.
Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol. 2008;103:788–97.
11. Mori T, Nagao G, Sugiyama M.Paraesophageal hernia
repair. Ann Thorac Cardiovasc Surg. 2012;18:297–305.
12. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg.
2002;236:492–500. discussion 500-501
13. Wolf PS, Oelschlager BK. Laparoscopic paraesophageal hernia repair. Adv Surg. 2007;41:199–210.
Techniques ofHiatal
Hernia Repair
BeatMüller-Stich, PhilipC.Müller, RudophPointner,
StavrosA.Antoniou, BurkhardH. A.vonRahden,
andSumeetK. Mittal
38.1 Dissection oftheHernia Sac – 395
38.2 Division ofShort Gastric Vessels – 396
38.3 Preservation oftheVagus Nerve – 397
38.4 Cruroplasty – 398
38.5 Fundoplication – 399
393
38
38.6 Mesh Augmentation – 401
References – 405
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_38
394
B. Müller-Stich et al.
38
. Fig.38.1 Classication of types of hiatal hernia.
Sliding hiatal hernia (type I), pure paraesophageal hernia
(type II), and type III as the combination of type I and II
Hiatal hernias are currently classied into type I–
IV hernias (. Fig. 38.1). In type I hernias, also
called sliding hernias, the gastroesophageal junction is situated above the diaphragm. ey are the
most common type of hiatal hernia with 80–85%
of all hiatal hernias. Type II–IV hernias are less
common and characterized by a paraesophageal
hiatal hernias. Type IV hiatal hernias are dened by
herniation of other abdominal organ than the stomach
involvement. Especially type II hernias are rare
and characterized as pure paraesophageal hernias. Type III hernias are a combination of type I
and type II hernias, the gastroesophageal junction, and the fundus herniate through the diaphragm. If an intra-abdominal organ other than
the stomach herniates, a type IV hernia is present.
Techniques ofHiatal Hernia Repair
395
38
Surgical treatment in type I hiatal hernia is only
indicated for concomitant gastroesophageal reux
disease. Hiatal hernias with paraesophageal
involvement should be operated if they are symptomatic because of the risk of progression and the
risk for complications such as incarceration. e
aim of the surgical therapy is the constant reposition of the hernia sac content and the repair of the
hiatus. Hiatal hernia repair can either be performed transabdominally or by transthoracic
access with an open or minimally invasive
approach. e laparoscopic approach is associated with reduced perioperative morbidity and
shorter hospital stay while showing equal symptomatic outcome compared to the open abdominal and the transthoracic approach. e minimally
invasive abdominal access is thus the preferred
approach for most hiatal hernias. Besides the
access, the dissection of the hernia sac, the type of
cruroplasty, the use of mesh augmentation, and
the addition of a fundoplication are factors that
have to be considered for an ideal hiatal hernia
repair. e chapter gives an evidence-based overview on the mentioned technical considerations,
and recommendations are made according to the
SAGES Guidelines and the latest literature
(. Tables 38.1 and 38.2).
38.1 Dissection oftheHernia Sac
. Table38.1 Levels of evidence and grade of
recommendation according to the Oxford Centre for
Evidence-Based Medicine (OCEBM Levels of Evidence
Working Group. “The Oxford 2011 Levels of Evidence”.
Oxford Centre for Evidence- Based Medicine) [40]
Level of
evidence
1a Systematic review of
1b Individual RCT with
2a Systematic review of
2b Individual cohort study
2c Outcome research
3a Systematic review of
3b Individual case-
4 Case series, poor-
5 Expert opinion D
Grading criteria Grade of
recommendation
A
RCTs including
meta-analysis
A
narrow condence
interval
B
cohort studies
B
and low-quality RCT
C
study
C
case-control studies
C
control study
C
quality cohort, and
case-control studies
e SAGES Guidelines for the management of
hiatal hernias recommend with the grade “strong”
that during hiatal hernia repair, the hernia sac
should be dissected away from the mediastinal
structures and with the recommendation “weak”
that the hernia sac should be excised. For both
recommendations, the quality of evidence is low
(
. Table38.2).
In hiatal hernias with paraesophageal involvement (types II–IV), the hernia sac has attachments
to the esophagus and stomach. Dissecting the hernia sac away from the mediastinum releases tension that otherwise draws the stomach upward
into the former position. When the sack has been
completely freed from its mediastinal attachments,
this force is eliminated, and the stomach will stay
tension-free within the abdomen (. Fig. 38.2).
Furthermore, a better orientation of the mediastinal structures, i.e., particularly the esophagus, and
an eective mobilization of the esophagus are
achieved, thus minimizing the risk for a manifest
short esophagus. Finally, a non-resection of the
hernia sac implies the risk of interposition, e.g.,
between the fundoplication and the esophagus
with consecutive dysphagia. Most surgical publications on hiatal hernia repair reported a complete
dissection of the sac and recommended a complete
excision [1, 10, 16, 17, 31, 34]. Little data comparing a complete with an incomplete dissection of
the hernia sac is available, especially no prospective or randomized controlled trials. In a comparative case series on primary paraesophageal hernia
repair by Edye et al., the surgical strategy was
changed aer 5 recurrences, which occurred in the
rst 25 patients within the rst 6months aer the
repair, when they did not completely resect the
hernia sac. Aer performing a complete excision
of the hernia sac in the next 30 patients, no early
recurrence was observed anymore [10]. In another
retrospective case series on large hiatal hernias