Table of contents
Hiatal hernia
Guidelines
Key sources
The following summarized guidelines for the evaluation and management of hiatal hernia are prepared by our editorial team based on guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024,2013).
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Classification and risk stratification
Classification: as per SAGES 2013 guidelines, classify hiatal hernias into the following types:
Situation
Guidance
Type I
Sliding hernias - the GEJ migrates above the diaphragm, the stomach remains in its usual longitudinal alignment and the fundus remains below the GEJ
Type II
Pure paraesophageal hernias - the GEJ remains in its normal anatomic position, but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus
Type III
A combination of types I and II, with both the GEJ and the fundus herniating through the hiatus, and the fundus lies above the GEJ
Type IV
Hiatal hernias with the presence of a structure other than stomach (such as the omentum, colon, or small bowel) within the hernial sac
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Diagnostic investigations
Perioperative care
Surgical interventions
Indications for surgery: as per SAGES 2024 guidelines, consider offering watchful waiting in adult patients with asymptomatic type II, III, or IV hiatal hernia if the diagnostic evaluation is unrevealing and the patient understands and accepts the risk of developing gastric volvulus.
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Choice of surgical approach
Technical considerations for surgery (hernial sac dissection)
Technical considerations for surgery (mesh use)
Technical considerations for surgery (fundoplication)
Technical considerations for surgery (esophageal length)
Technical considerations for surgery (gastropexy)
Technical considerations for surgery (gastrotomy tube)
Specific circumstances
Patients undergoing bariatric surgery: as per SAGES 2013 guidelines, repair any hiatal hernia detected during Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band placement.
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Pediatric patients (indications for surgery)
Pediatric patients (technical considerations for surgery)
Follow-up and surveillance
Management of recurrent hernia
As per SAGES 2024 guidelines:
Consider converting to Roux-en-Y gastric bypass in selected patients without obesity and with recurrent type II, III, or IV hiatal hernia.
Perform redo hiatal hernia repair and fundoplication in patients with recurrent hiatal hernia after a previous uncomplicated hiatal hernia repair with fundoplication. Consider performing Roux-en-Y gastric bypass in patients with diabetes mellitus, severe esophageal dysmotility, short esophagus, or gastroparesis, patients with previous complicated hiatal hernia repair with fundoplication having poor quality tissue of the fundus, and patients after multiple recurrent hiatal hernia failures by an expert.
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