Paraesophageal Hernia (Hiatal Hernia)

What is a hiatal hernia?
Any time an internal body part pushes into an area where it doesn't belong, it's called a hernia. The hiatus is an opening in the diaphragm - the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus goes through the hiatus and attaches to the stomach. In a hiatal hernia, the stomach bulges up into the chest through that opening. There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).

In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia. These sliding hiatal hernias are a risk factor for gastroesophageal reflux disease (GERD), and many patients with hiatal hernias suffer from GERD symptoms such as heartburn. Sliding hiatal hernias are very common and as many as more than 1 in 4 adults has one by the time they reach the age of 40.

The paraesophageal hernia is less common but is more cause for concern. In many patients, paraesophageal hernias may not cause any symptoms. These asymptomatic paraesophageal hernias can be safely observed and do not require surgery. When a paraesophageal hernia begins to cause symptoms (chest pain, upper abdominal pain, difficulty swallowing), these are usually repaired. Symptomatic paraesophageal hernias are at higher risk for progressing to incarceration (stomach gets stuck resulting in obstruction) or ischemia (blood supply to the stomach is cut off) resulting in the need for emergency surgery.

When should a sliding hiatal hernia be repaired?
Hiatal hernias are known to contribute to GERD. When diet, lifestyle modifications (lose weight, don’t eat late at night, sleep upright), and acid reduction medications fail to adequately control symptoms, hiatal hernia repair may be indicated. See our web page on GERD for more information.

When should a paraesophageal hernia be repaired?
In general, all paraesophageal hernias causing symptoms should be repaired. Common symptoms from a paraesophageal hernia include:

  • Chest pain—there are many causes for chest pain. It is important that patients who have a large paraesophageal hernia with chest pain undergo some kind of a cardiac evaluation to make sure that the chest pain is not from their heart. Typically, eating brings on chest pain from a paraesophageal hernia. Some patients have pain every time they eat, and others only experience discomfort every once in a while.
  • Epigastric pain—this is pain in the middle, upper abdomen.
  • Dysphagia—difficulty swallowing.
  • Shortness of breath—in some very large paraesophageal hernias, the stomach may push on the diaphragm or compress the lungs contributing to a sensation of shortness of breath. There are many other reasons for shortness of breath in addition to a paraesophageal hernia.
  • Early or prolonged satiety—Because the stomach is twisted or compressed due to the hernia, it may be difficult for patients to eat a normal sized meal. Patients may feel full for a very long time after eating, which is due to the fact that the stomach can’t empty normally when it is herniated. Some patients may lose weight because of difficulty eating.
  • Stomach ulcer—in some patients with paraesophageal hernias, the stomach may twist upon itself resulting in a specific kind of stomach ulcer known as a Cameron’s erosion. These ulcers can occasionally contribute to chronic slow blood loss and anemia.

Many patients (but not all) with paraesophageal hernias may also suffer from gastroesophageal reflux disease symptoms. GERD by itself is not a reason to repair a paraesophageal hernia. GERD is first treated with medications, and surgery is reserved for those who fail medical management.

For an in-depth discussion on whether a paraesophageal hernia should be repaired, please make an appointment with one of our surgeons.

Can a paraesophageal or a hiatal hernia cause pain in my back?
A sliding hiatal hernia will not cause back or epigastric pain like a paraesophageal hernia can. Sliding hiatal hernias can cause GERD symptoms. A very large paraesophageal hernia could potentially cause back pain, but this is not a common symptom. The most common pains related to a paraesophageal hernia are chest and epigastric (upper abdomen) pain, most often during or shortly following eating.

How are paraesophageal hernias repaired?
Almost all paraesophageal hernias can successfully and safely be repaired laparoscopically (with about 5 very small incisions) and through the abdomen (rather than the chest cavity). The laparoscopic repair of large paraesophageal hernias (most of the stomach resides above the diaphragm in the chest cavity) is a complex procedure and should only be attempted by expert laparoscopic surgeons with extensive experience in laparoscopic foregut surgery.

During surgery, the stomach is gradually moved back into the abdominal cavity. The diaphragm at the esophageal hiatus is closed to prevent the stomach from re-herniating. In some cases, a special kind of mesh is needed to close the diaphragm appropriately. Once the diaphragm has been closed, most patients undergo a fundoplication or a ‘wrap’ similar to what is done for a patient with GERD. The fundoplication is performed to help keep the stomach from herniating back into the chest cavity.

What are the results of paraesophageal hernia repair?
In the hands of experienced surgeons, the results of laparoscopic paraesophageal hernia repair are excellent. A minimally invasive laparoscopic approach results in significantly fewer complications than an open abdominal approach (many small incisions instead of one large incision in an open approach). Most patients are in the hospital for only 1-2 days and are back to their usual activities within 4 weeks.

Side effects can occur and are similar to those observed after laparoscopic Nissen fundoplication. Abdominal bloating can occur but is rarely severe. Difficulty swallowing (dysphagia) is another side effect that tends to improve in most patients with time – provided food is chewed thoroughly. The majority of patients are able to belch easily when necessary; especially once some time has passed following surgery.

For a more detailed discussion about the options, risks, and outcomes of paraesophageal hernia repair, and to determine if a patient is a candidate for a laparoscopic repair, please make an appointment with a fellowship trained minimally invasive gastrointestinal surgeon in the Division of Minimally Invasive and Gastrointestinal Surgery at the Medical College of Wisconsin.

"Elective Repair of Paraesophageal Hernia is Safe"