Guidelines for the Management of Hiatal Hernia Diagnosis

Hiatal hernia can be diagnosed by various modalities. Only investigations which will alter the clinical management of the patient should be performed (+++, strong)

Indications for Surgery

• Repair of a type I hernia in the absence of reflux disease is not necessary (+++, strong)

• All symptomatic paraesophageal hiatal hernias should be repaired (++++, strong), particularly those with acute obstructive symptoms or which have undergone volvulus.

• Routine elective repair of completely asymptomatic paraesophageal hernias may not always be indicated. Consideration for surgery should include the patient’s age and co-morbidities. (+++, weak)

• Acute gastric volvulus requires reduction of the stomach with limited resection if needed. (++++, strong)

Repair of Hiatal Hernia During Bariatric Operations

• During operations for Roux-en-Y gastric bypass, sleeve gastrectomy and the placement of adjustable gastric bands, all detected hiatal hernias should be repaired (+++, weak)

Predictors of Outcomes

• Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes (++, strong)

Technical Considerations

• Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach (++++, strong). The morbidity of a laparoscopic approach is markedly less than that of an open approach (++, strong)

• Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias (++++, strong)

• During paraesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal structures (++, strong), and then preferably excised (++, weak)

• The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term recurrence rates (+++, strong)

• There is inadequate long-term data on which to base a recommendation either for or against the use of mesh at the hiatus

• A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux. A fundoplication is also important during paraesophageal hernia repair. (++, weak)

• In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may not be necessary (++, weak)

• A necessary step of hiatal hernia repair is to return the gastroesophageal junction to an infradiaphragmatic position (+++, strong)

• At the completion of the hiatal repair, the intra-abdominal esophagus should measure at least 2 – 3cm in length to decrease the chance of recurrence (++, weak). This length can be achieved by combinations of mediastinal dissection of the esophagus and/or gastroplasty (++++, strong)

• Gastropexy may safely be used in addition to hiatal repair (++++, strong)

• Gastrostomy tube insertion may facilitate postoperative care in selected patients (++, strong)

• Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients but may be associated with high recurrence rates (++, weak). Formal repair is preferred (++++, strong)

Postoperative Management

• With early postoperative dysphagia common, attention should be paid to adequate caloric and nutritional intake (+, strong)

• Routine postoperative contrast studies are not necessary in asymptomatic patients (+++, strong)

Revisional Surgery

• Revisional surgery can safely be undertaken laparoscopically by experienced surgeons (+++, strong)

Pediatric Considerations

Indications for surgery

• Symptomatic hiatal hernias in children should be surgically repaired (++, weak)

• A laparoscopic approach in children is feasible. Age or size of the hernia should not be an upfront contraindication to laparoscopy (++, weak)

Technical considerations

• Gastroesophageal reflux in pediatric patients with a hiatal hernia should be addressed by a concomitant anti-reflux procedure (++, weak)

• The current standard of care in children is either excision of the hernia sac or disconnection of the sac from the crura (+++, weak)

• To lower the risk of postoperative paraesophageal hernia after fundoplication in the pediatric population, minimal hiatal dissection should be performed (++, weak)

• Plication of the esophagus to the crura may decrease recurrence in children (+, weak)

Table 1: GRADE system for rating the quality of evidence for SAGES guidelines

Quality of Evidence

Definition

Symbol Used

High qualityFurther research is very unlikely to alter confidence in the estimate of impact

++++

Moderate qualityFurther research is likely to alter confidence in the estimate of impact and may change the estimate

+++

Low qualityFurther research is very likely to alter confidence in the estimate of impact and is likely to change the estimate

++

Very low qualityAny estimate of impact is uncertain

?

GRADE recommendations based on the quality of evidence for SAGES guidelines

StrongIt is very certain that benefit exceeds risk for the option considered

WeakRisk and benefit well balanced, patients and providers faced with differing clinical situations likely would make different choices, or benefits available but not certain regarding the option considered

Adapted from Guyatt et al