Treatment and prognosis

Surgery is indicated for all symptomatic para-oesophageal hernia particularly those with acute obstructive symptoms or which have undergone volvulus

• in majority of cases there is severe anatomical distortion making laproscopic repair a complex operation
• hernia sac is completely resected from the mediastinum, oesophagus is mobilized, hiatus is closed (sometimes using mesh), and fundoplication
• the risk of surgery must be balanced against the underlying risk of complications from paraesophageal hernia before considering surgery (1,2)

Routine elective repair may not be necessary in completely asymptomatic paraesophageal hernias. Patient’s age and co-morbidities should be taken into account before surgery (1,2)

• progression from asymptomatic to symptomatic paraesophageal hernia is thought to be around 14% per year
• the risk of developing acute symptoms that require emergency surgery is less than 2%

If strangulation has already taken place, emergency gastric resection is required.

Recurrence rate for paraesophageal hernia after repair is up to 50% at five years (2).

Reference:

• (1) Kohn GP et al. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409-28.
• (2) Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g6154