Hiatal hernia

it is my presentation which is given in thoracic ward to brief about about hiatal hernia and new advancement which is in new era

1. 60 years old female H/O experiencing pain about an inch beneath her sternum and sharp pains in radiating towards her left shoulder. It varies in intensity and is increased immediately after eating spicy foods. After most meals, she c/o suffering from mild heartburn. She is on course of Omeprazole, which alleviated the symptoms, but they returned after a few days if she discontinue the PPI.

2. Anatomy The esophageal hiatus is formed by muscle fibers of the right crus of the diaphragm, with little or no contribution from the left crus. These fibers overlap inferiorly where they attach over and along the right side of the median arcuate ligament, which is attached to the lateral aspects of vertebral bodies. The phrenicoesophageal ligament is formed by fusion of the endothoracic and endoabdominal fascia at the diaphragmatic hiatus. This ligament inserts onto the esophagus and holds the distal esophagus

3. Hiatus hernia It is defined as “The herniation of abdominal contents into the chest through the esophageal hiatus” . May occur as a result of a Congenital defect Trauma After antireflux or other hiatal hernia operations

4. Hiatal Hernia Types

5. Type I Sliding hernia. The GE junction is located above the level of the diaphragm by upward herniation of the cardia into the posterior mediastinum. This is the most common type and frequently associated with GERD.

6. Type II The GE junction and cardia of the stomach are located below the level of the diaphragm; however, the fundus of the stomach has entered the mediastinum adjacent to the GE junction. This is a true paraesophageal hernia (PEH) and represents the rarest type.

7. Type III Hernias are a combination of Types I and II, with both the GEJ and the fundus herniating through the hiatus. The fundus lies above the GEJ also called giant PEH . This is the most common type found when surgical intervention is required.

8. Type IV Similar to type III with the addition of another structure herniated into the mediastinum, such as colon, spleen, small bowel, liver, or pancreas.

9. Epidemiology Sliding hernia greater then 95% PEHs account for approximately 5% to 15%. 3% to 6% of all patients undergoing surgical repair of hiatal hernias. Obesity, Kyphosis or scoliosis are risk factor for developing a hiatal hernia. In children, congenital defects are the most common cause of PEH.

10. Symptoms Early Satiety Dysphagia Regurgitation Respiratory Complications

11. Sign Acute gastric bleeding One-third of patients with PEHs are anemic due to Saddle or Cameron’s lesions Obstruction 30% of patients with PEHs presented with gastric volvulus Strangulation Perforation infarction

12. Diagnosis

13. Chest x-ray

14. B arium study of the esophagus helps establish the diagnosis with greater accuracy .  

15. Endoscopy Identify fibrotic stricture, esophageal neoplasm, epiphrenic diverticulum, barrett’s esophagus or esophagitis . Identify intragastric ulcers and diagnosis GERD associated with hiatal hernia

16. CT Scan

17. Esophageal manometry

18. TREATMENT   OPTIONS   The goals of treatment are to relieve symptoms and prevent further complications. Reducing the gastroesophageal reflux will relieve pain. Other measures to reduce symptoms include: Avoiding large or heavy meals Not lying down or bending over immediately after a meal Reducing weight and stop smoking If these measures fail to control the symptoms, or complications occur, surgical repair of the hernia may be necessary.

19. Endoscopic procedures Stretta procedure - EsophyX

20. Surgical Options Open Thoracotomy Laparotomy Minimally invasive Laparoscopic Transthoracic Belsey Mark IV (240 A) Anti-reflex procedure - Nissen’s fundoplication (360 ○ P) - Toupet’s fundoplication (270 ○ P) - Dor fundoplication (180 ○ A)

21. Surgical Options Neoesophagus - Collis gastroplasty Shortening Gastropexy by placement of a gastrostomy tube can be a useful adjunct in poor operative candidates or in emergency situations. Gastric bypass with crural repair in severely or morbidly obese

22. Port Placement

23. Left to right opening of the phreno-oesophageal ligament Preservation of the hepatic branch of the anterior vagus nerve Dissection of both crura Transhiatal mobilization to allow approximately 3 cm of intra-abdominal oesophagus, Short gastric vessel division to ensure a tension-free wrap Crural closure posteriorly with non-absorbable sutures Creation of a 1.5 to 2-cm wrap with the most distal suture incorporating the anterior muscular wall of the oesophagus . Bougie 58fr placement at the time of wrap construction. Standardized Nissen fundoplication

24. Intraoperative complication P neumothorax Bleeding Esophageal or gastric perforation Vagal injury

25. Early Post-operative complication Subcutaneous crepitance in chest, neck and even head Wound infection Atrial Fibrillation DVT

26. Long-term Post-operative complication Dysphagia Belching Gas Bloat Pulmonary symptoms Weight loss Slipped Nissen Recurrence of PEH Slipped Nissen

27. SAGES Guidelines for the Management of Hiatal Hernia 2013

28. Repair of a type I hernia in the absence of reflux disease is not necessary ( +++, strong ) All symptomatic paraoesophageal hiatal hernias should be repaired ( ++++, strong ), esp. acute obstructive symptoms or volvulus. Acute gastric volvulus requires reduction of the stomach with limited resection if needed. ( ++++, strong ) Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach ( ++++, strong ). During paraoesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal structures ( ++, strong ) and then preferably should not excised ( ++, strong ) The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term recurrence rates ( +++, strong )

29. A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux A necessary step of hiatal hernia repair is to return the GEJ to an infra-diaphragmatic position ( +++, strong ). This length can be achieved by combinations of mediastinal dissection of the oesophagus and/ or gastroplasty ( ++++, strong ) Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients. Gastropexy may safely be used in addition to hiatal repair ( ++++, strong ) Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes ( ++, strong ) Gastrostomy tube insertion may facilitate postoperative care in selected patients ( ++, strong ) With early postoperative dysphagia common, attention should be paid to adequate caloric and nutritional intake ( +, strong )

30. Routine elective repair of completely asymptomatic PEH may always be indicated. Consideration for surgery should not include the patient’s age and comorbidities. ( +++, strong ) During operations for Roux-en-Y gastric bypass, sleeve gastrectomy and the placement of adjustable gastric bands, all detected hiatal hernias should no be repaired ( +++, strong ) . A fundoplication is not important during PEH repair . ( ++, strong ) In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may be necessary ( ++, strong ) Recurrence can be reduced by extensive mediastinal oesophageal mobilization to bring the GEJ at least 2-3 cm into the abdomen without tension ( ++, strong ).

31. Aftercare Diet & Medication Liquids 1 st -2 nd week Mashed/soft diet 2 nd –4 th week Solids 5 th -6 th week Small mouthfuls Chew well Swallow slowly Avoid tablets/capsules 6 weeks

32. Aftercare Activity Walk as normal Buildup physical activity over 6-8 weeks Strenuous activity permitted after 6 weeks. Avoid driving for 3-4 weeks Sexual relations can resume when comfortable

33. PROGNOSIS   Symptomatic relief post operatively greater than 80% . With or without the use of mesh, the recurrence rate of hiatal hernias is between 20 and 40 % even in large-volume centers . O perative mortality rate for emergent repair of incarcerated PEH is 50% .