Paraesophageal Hiatus Hernia

Paraesophageal (type II) hiatus hernia represents a dis-• tinct anatomic and clinic entity requiring a unique therapeutic strategy, and is differentiated from the more common type I (sliding) hiatus hernia. All symptomatic patients, in the absence of prohibitive • operative risk, should undergo elective repair to prevent life-threatening complications, such as obstruction, strangulation , perforation, and bleeding. Extended transmediastinal dissection and complete sac • excision are mandatory to reduce the stomach and the distal esophagus safely into the abdomen; a Collis gastro-plasty is necessary only infrequently. The anterior sac can be left attached to the cardia and used • for downward traction; identify and avoid injury to the anterior vagus nerve. A retrogastric lipoma is constant and should be excised to • enable complete dissection of the diaphragmatic pillars behind the esophagus; identify and avoid injury to the posterior vagus nerve. Crural repair with prosthetic patch onlay has the potential • to reduce the recurrence rate but insufficient data are available at present to confirm safety, best prosthetic, and long-term effectiveness. 18 L. Bonavina The addition of a Nissen-or Toupet-fundoplication tech-• niques reduces the incidence of postoperative gastroe-sophageal reflux. The role of a concomitant anterior gastropexy constructed • to prevent intraabdominal gastric volvulus and recurrent hernia remains controversial. Laparoscopic repair is feasible and remains the approach • of choice in patients with paraesophageal hiatus hernia. Hiatal hernias are heterogeneous anatomic and clinical entities. Classification into four types is widely accepted. Sliding hernia is the result of an upward migration of the esophago-gastric junction into the mediastinum (type I hiatus hernia). Paraesophageal hiatus hernia (type II hiatus hernia) occurs as a result of an anterior defect in the diaphragmatic hiatus leading to an upward dislocation of the gastric fundus alongside the cardia. Subsequent progressive enlargement of the hiatus and the hernia sac leads to a mixed paraesophageal and sliding hernia (type III hiatus hernia) which may evolve to the final stage characterized by a complete, intrathoracic, " upside-down " stomach. Therefore, the distinction between type II and type III hernias is somewhat artificial because they are considered a continuous disease spectrum. Infrequently, the colon can migrate into the hernia sac (type IV hiatus hernia). Approximately 10% of hiatus hernias have a paraesopha-geal component, and among these patients, 90% have a mixed type III hernia. The true incidence of paraesophageal hernia in the overall population is unknown because of minimal or even …