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Page 2 of 12 Ugliono et al. Mini-invasive Surg 2021;5:2 I http://dx.doi.org/10.20517/2574-1225.2020.93

INTRODUCTION
Hiatal hernia (HH) is the protrusion of an abdominal organ into the mediastinum through the
diaphragmatic hiatus.

There are four main types of HH: Type 1 (“sliding”), the most common, is the herniation of the esophago-
gastric junction (EGJ) above the diaphragm, leaving the stomach in the abdomen; Type 2 (“pure
paraesophageal”) is the thoracic migration of the gastric fundus while the EGJ remains in the correct
position; Type 3 (“mixed”) is a combination of both Type 1 and Type 2 components; and, in Type 4 (“giant”)
HH, the herniation involves the entire stomach along with other abdominal viscera, including colon,
[1]
omentum, small bowel, liver and spleen . Types 2-4 HH are defined as paraesophageal hernias (PEH) and
[2]
share the same preoperative work-up and surgical treatment .
Clinical manifestations of PEH include obstructive (dysphagia and postprandial fullness) and compressive
(respiratory complications and recurrent pneumonia) symptoms, gastroesophageal reflux (GER) (heartburn
and regurgitation), and chronic anemia. PEH can also present acutely with complications: bleeding, acute
[3]
obstruction, and strangulation resulting in gastric necrosis .

The diagnosis is made with upper endoscopy and barium esophagogram, to assess the morphology of HH.
Other examinations, such as computed tomography scan and esophageal manometry, could be helpful in
[1,4]
treatment planning, but they are not mandatory .

INDICATIONS FOR SURGERY
Elective vs. emergent
In contrast to Type 1 sliding HH, which does not require surgical intervention unless in the presence of
[5]
severe GER, PEH carries the potential for severe acute complications .

In the past, PEH repair was proposed for all surgically fit patients, regardless of symptoms, due to previous
studies demonstrating an unacceptably high mortality rate (ranging 29%-56%), associated with acute
[6,7]
presentations .
[8]
A study from Stylopoulos et al. changed this paradigm. The authors performed a Markov Monte Carlo
decision analysis to address the optimal treatment strategy for PEH. The input variables considered,
obtained from a systematic review of the literature and data of the 1997 Nationwide Inpatient Sample, were:
the estimated mortality rate after elective laparoscopic (1.4%, range 0%-5.2%) and emergency (5.4%) PEH
repair, the annual probability of developing symptoms progression (13.8% range 8.1%-21.7%), the annual
probability of acute presentation requiring emergency surgery of untreated patients (1.1% range 0.7%-1.9%),
and the annual probability of HH recurrence after surgical repair (1.9% range 0.3%-5.4%). With these
assumptions, the authors estimated that watchful waiting would be the optimal treatment for 83% of PEH
patients, as the risk of developing life-threatening complications is only 1.1% per year.

Since then, other studies have demonstrated lower mortality rates associated with PEH repair, both in the
elective and in the emergency setting [9,10] . Even with these new reports, an updated study using the same
[11]
statistical methodology achieved the same conclusions in terms of mortality . However, considering cost-
[12]
effectiveness, a similar study performed by Morrow et al. concluded that elective repair, although more
expensive, guarantees superior quality of life compared to watchful waiting. Current guidelines recommend
the elective repair of all symptomatic PEH, while in asymptomatic patients the indications to elective
[5]
surgery must be balanced with the patient’s age and comorbidities .