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Hiatal hernias are similar to all other hernias in that they contain intra-abdominal organs, such as the stomach, colon, intra-abdominal fat, and small bowel, but their location is hidden from the outside of the body. This hernia occurs at the hiatus which is a normal defect in the diaphragm. Nature has provided this defect in the diaphragm to allow the esophagus to pass into the abdomen. In the case of a hiatal hernia, the intra-abdominal organs herniate through the hiatus. The most common hiatal hernia organs to herniate are the esophagus and stomach.

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Normal anatomy showing the esophagus passing through the diaphragm             Hiatal hernia showing the stomach above the level of the diaphragm

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Causes

There are several causes of a hiatal hernia. Probably the most common cause in the United States of a hiatal hernia is obesity. A hiatal hernia appears to be directly related to intra-abdominal pressure. Obesity causes increased intra-abdominal pressure which pushes the stomach against the diaphragm, up into the hiatus, and into the chest. The result is a hiatal hernia. Other causes can be from the trauma that is a sudden increased pressure in the abdomen, a weak phreno-esophageal ligament which is the ligament that attaches the esophagus to the hiatus, and pregnancy.

Diagnosis

A diagnosis of a hiatal hernia can be made several ways. The most common way is by upper endoscopy. This means that a surgeon or gastroenterologist uses an endoscope to look inside your esophagus, stomach and the first part of your small bowel called the duodenum. As the endoscope passes down the esophagus and into the stomach, it will be noted that the stomach is above the hiatus and in the chest. This makes the diagnosis of a hiatal hernia. Additional ways to diagnose a hiatal hernia are with an upper GI swallow study in which barium is commonly used, and through a CT scan. There are other ways to diagnose a hiatal hernia, but these are the most common. Most importantly, one of these exams needs to be done to make the diagnosis of a hiatal hernia because it can not be made from a physical exam or by symptoms. Often times symptoms can raise suspicion for a hiatal hernia, but does not definitively make the diagnosis without one of these tests.

Treatment

A hiatal hernia can only be treated with surgery. This is the same case for all other hernias. They do not get better on their own, and they only get worse over time. Often times, patients can help with some of the symptoms of weight loss in the situation of obesity, but that still does not improve the actual hiatal hernia. This is a common misconception by patients.

Since symptoms often indicate that there is a hiatal hernia, patients are often prescribed Proton Pump Inhibitors, or PPIs, such as Protonix, Pepcid, Dexilant, etc. These medications only suppress the acid production in the stomach which will alleviate the heartburn symptom by changing the pH of stomach secretions. They do not fix the hiatal hernia! There is no medication to fix a hiatal hernia.

A hiatal hernia obliterates the natural reflux barrier, so stomach secretions can freely splash up into the esophagus regardless of the use of PPIs. Overtime, the irritation in the esophagus from a hiatal hernia and stomach secretions causes changes to the lining. The terms used to describe these changes are words like metaplasia, dysplasia, Barrett's Esophagus, and esophageal cancer. Repairing the hiatal hernia will stop this progression, and is thought to reverse it.

Surgery

Repairing a hiatal hernia is done with an abdominal or thoracic approach. Most commonly, Hiatal hernias are repaired through an abdominal approach and are done in a minimally invasive fashion. Surgeons will utilize a laparoscopic or robotic approach for repair of a hiatal hernia. In both situations, small incisions are used to repair a hiatal hernia with a camera and small instruments. A minimally invasive approach has been shown to minimize recovery time, post operative complications, and use of pain medications.


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Minimally Invasive Laparoscopic Procedure

There are different types of Hiatal hernias and are classified into 4 categories:

  • Type 1 – Sliding hernia
  • Type 2 – Paraesophageal hernia (appropriate location of esophagus)
  • Type 3 – Paraesophageal hernia (esophagus retracted into the chest)
  • Type 4 – Other organs (such as colon) in the hiatal hernia

The repair of these Hiatal hernias differs in their repairs from the surgeon's aspect. It is at the surgeon's discretion to use a mesh to help repair the hiatal hernia.

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Hiatal Hernia