Transthoracic Hiatal Hernia Repair



Transthoracic Hiatal Hernia Repair


Jules Lin

Mark Orringer






PATIENT HISTORY AND PHYSICAL FINDINGS



  • A detailed history and physical must be performed focusing on heartburn and reflux symptoms, response to medical treatment as well as the characteristics and degree of dysphagia, regurgitation, pain, bloating, or anemia. In a series of 240 patients with a paraesophageal hernia, Patel et al.4 found that 68% of patients had reflux symptoms, 67% abdominal or chest pain, 33% anemia, and 33% dysphagia. The absence of severe reflux symptoms in most patients with paraesophageal hiatal hernias does not diminish the seriousness of this problem with its unpredictable potential for strangulation, perforation, bleeding, and aspiration pneumonia. More subtle symptoms may include early satiety and/or left shoulder and back pain with eating, loud borborygmi often heard across the room by the patient’s family, or acute shortness of breath with bending forward.


  • Any previous chest or abdominal operations or endoscopic dilations should be noted.


  • The history should include the patient’s current functional status and exercise tolerance.


  • A complete physical examination should be performed with attention to auscultation of the heart and lungs and palpation of the abdomen.


  • Routine laboratory studies, including a complete blood count and a basic chemistry panel, should be included as part of the preoperative evaluation.


IMAGING AND OTHER DIAGNOSTIC STUDIES



  • A chest x-ray (FIG 2) may show a mediastinal air fluid level, suggesting the presence of a paraesophageal hernia.


  • A barium swallow (FIG 3) should be performed to delineate the esophageal and gastric anatomy and may show reflux, although this is not a reliable finding. Accompanying esophageal dysmotility from the “accordioned” esophagus is common. The esophagram can also be useful when obstruction from gastric volvulus is suspected (FIG 4).


  • An esophagoscopy (FIG 5) should be performed to evaluate for evidence of esophagitis, Barrett’s mucosa, esophageal carcinoma, or esophageal shortening. Suspicious areas should be biopsied. The gastric mucosa should also be examined for Cameron erosions, especially when there is a history of anemia. Caution should be exercised to avoid excessive air insufflation during flexible esophagogastroscopy in the patient with a paraesophageal hiatal hernia lest the intrathoracic stomach becomes overdistended, resulting in hemodynamic instability.


  • For patients complaining of persistent nausea, a gastric emptying study may be obtained to evaluate for gastroparesis.


  • When there is no hiatal hernia or a small sliding hiatal hernia, esophageal manometry and 24-hour pH probe monitoring with impedance are performed, with antireflux medications discontinued for 72 hours, to document the presence of gastroesophageal reflux, association with the patient’s symptoms, and to evaluate for esophageal dysmotility. However, in the presence of a paraesophageal hernia, we do not routinely perform these studies. Many of these patients will have some degree of dysmotility in the presence of a chronic hiatal hernia that frequently improves after hiatal hernia repair. The presence of a symptomatic hiatal hernia is a mechanical issue, and the indication for repair is the paraesophageal hernia itself regardless of the presence of acid reflux.


  • Patients suspected of having an incarcerated hiatal hernia (FIG 4) with severe epigastric pain and regurgitation should undergo an esophagram and nasogastric tube decompression followed by an emergent hiatal hernia repair.






FIG 2 • Chest x-ray demonstrates an air fluid level (arrowhead) consistent with a type III hiatal hernia.






FIG 3 • Barium swallow demonstrating a type III paraesophageal hernia.







FIG 4A. Chest x-ray and (B) barium esophagram showing an incarcerated type III hiatal hernia with complete obstruction requiring emergent repair.


SURGICAL MANAGEMENT


Jul 24, 2016 | Posted by in GENERAL | Comments Off on Transthoracic Hiatal Hernia Repair

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