Early results with the Lichtenstein tension-free hernia repair

Paraesophageal hernia: clinical presentation, evaluation, and management controversies

Practically, hiatal hernias are divided into sliding hiatal hernias (type I) and PEH (types II, III, or IV). Patients with PEH are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. Rarely, patients present with acute symptoms of hernia incarceration, such as severe epigastric pain and retching. A thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry. These investigations define the patient's anatomy, rule out other disease processes, and confirm the diagnosis. Operable symptomatic patients with PEH should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. Debate remains whether a transthoracic, transabdominal, or laparoscopic approach is best with good surgical outcomes being reported with all three techniques. Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long-term follow-up is required to determine whether the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice.

Current controversies in paraesophageal hernia repair

The management of paraesophageal hernia (PEH) has become one of the most widely debated and controversial areas in surgery. PEHs are relatively uncommon, often presenting in patients entering their seventh or eighth decades of life. Patients who have PEH often bear complicating medical comorbidities making them potentially poor operative candidates. Taking this into account makes surgical management of these patients all the more complex. Many considerations must be taken into account in formulating a management strategy for patients who have PEHs, and these considerations have led surgeons into ongoing debates in recent decades.