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Hiatal hernia

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 2013).
1

Guidelines

1.Classification and risk stratification

Classification: 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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2.Diagnostic investigations

Diagnostic strategy: recognize that hiatal hernia can be diagnosed by various modalities. Obtain only investigations that will alter the management.
B

3.Surgical interventions

Indications for surgery: avoid repairing type I hernias in the absence of reflux disease.
D
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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)

4.Specific circumstances

Patients undergoing bariatric surgery: repair any hiatal hernia detected during Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band placement.
B

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  • Pediatric patients (indications for surgery)

  • Pediatric patients (technical considerations for surgery)

5.Follow-up and surveillance

Postoperative care: do not obtain routine postoperative contrast studies in asymptomatic patients after hiatal hernia repair.
D
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  • Revisional surgery