Diaphragmatic Hernia

The sliding hiatus hernia is the most common type of diaphragmatic hernia. A portion of the stomach just below the esophagogastric junction and the abdominal esophagus rises into the chest. In paraesophageal hernia, the esophagogastric junction remains in place, but the stomach rises alongside the esophagus. Combinations of sliding and paraesophageal hernias occur.

Sliding Hiatus Hernia

A small hiatus hernia can be detected in most elderly persons. Such hernias are almost always asymptomatic, unless the patient has reflux esophagitis. However, mild flatulence or substernal discomfort may occur, and if a Schatzki's ring tightens to a diameter < 11 mm, esophageal obstruction can develop.

The diagnosis is based on barium contrast studies, endoscopy, and 24-hour esophageal pH monitoring. The differential diagnosis includes coronary artery disease, esophageal spasm, gallbladder disease, gastritis, peptic ulcer, and functional complaints for which no organic cause can be found. Symptoms that appear suddenly suggest malignant disease, not only of the esophagus but of any abdominal organ. Consequently, an abdominal rather than a thoracic approach is used for repair because an unexpected tumor may be found.

Asymptomatic hernias should not be repaired. Mild complaints are treated by conservative measures, including a bland diet, weight reduction, antacids, and nighttime elevation of the head and chest using several pillows or blocks under the bed supports.

Controversy continues concerning the best surgical procedure for hiatus hernia complicated by esophagitis. Each procedure restores a proper length of abdominal esophagus and strengthens the lower esophageal sphincter. In the Nissen repair, the fundus of the stomach is wrapped around the lower esophagus. In the Belsey repair, a valve is created by suturing the stomach to the anterior surface of the esophagus. In the Hill repair, the part of the stomach at the gastroesophageal junction is anchored to the median arcuate ligament, which lies just anterior to the aorta; a valve is created by anterior sutures through the junction, drawing it back toward the ligament. Laparoscopic Nissen fundoplication has gained wide acceptance during the past few years and is a good option for the patient who has not had previous upper abdominal surgery.

Regardless of the procedure, postoperative recurrences after several years are common, perhaps because of the negative intrathoracic pressure that occurs with every inspiration. Nevertheless, surgery offers great relief for long periods in selected patients. In a few cases, esophagitis is so marked that resection and replacement with a section of jejunum or colon is necessary. In some elderly patients, recurrent strictures at the gastroesophageal junction can be treated by periodic dilation with bougies.

Paraesophageal Hernia

Paraesophageal hernias can be huge, with the entire stomach in the chest. Both the esophagogastric junction and the pylorus may be level with the diaphragm as the gastric fundus rotates upward into the left or right side of the chest. A large gas bubble can be seen on chest x-ray, and the diagnosis is confirmed by barium contrast studies.

Paraesophageal hernias can cause complete pyloric obstruction and gastric incarceration, strangulation, and perforation. Unless the patient is a poor surgical risk, these hernias should be repaired.

Hernia Due to Diaphragmatic Rupture

After an injury to the left side of the chest or the left upper abdominal quadrant, a chest x-ray may show a gas bubble above the diaphragm on the left side, suggesting a diaphragmatic rupture. Barium contrast studies, MRI, or laparoscopy should be performed. If a traumatized patient goes to the operating room for other injuries and a diaphragmatic injury is suspected, laparoscopy is the diagnostic modality of choice. The stomach is the usual organ found to be in the chest, but the colon, spleen, and even other viscera are identified in some cases. Immediate repair is necessary.