12 
Sliding and Paraesophageal Hiatal
Hernias Types 1, 2, and 3
Hiatal hernias develop in 10% to 50% of the population with an average
age of 48 for patients with a sliding hernia and 65 to 75 for a paraesopha-
geal hernia. There are four types of hiatal hernias. Type 1, accounting
for over 90% of all hernias, develops when the gastroesophageal junction
(GEJ) slides above the diaphragm. The remaining hernias, 10%, are
either type 3 or mixed type 2, which is a pure paraesophageal hernia.
Type 2 hernias develop when the gastric fundus herniates into the chest,
lateral to the esophagus, but the GE junction remains fixed in the
abdomen; these account for 14% of the remaining 14% of hernias.
Type 3, or mixed paraesophageal hernias, account for 86% of the remain-
ing 14% of hernias. They develop with movement of the lower esophageal
sphincter (LES) and the fundus into the chest (Figs. 12.1 and 12.2).
The type 4 hernia is a subset of type 3 and contains not only the entire
stomach but also other viscera, such as the omentum, colon (13%),
spleen (6%), and small bowel. Parahiatal hernia is movement of the
stomach through a diaphragmatic defect separate from the hiatus and
accounts for less than 1% of all hiatal hernias.
A hiatal hernia forms as the phrenoesophageal membrane, preaortic
fascia, and median arcuate ligament become attenuated over time. The
pressure differential between the abdomen and the chest creates a vacuum
effect during inspiration that pulls on the stomach. The degree of her-
niation into the posterior mediastinum and the type of volvulus that
occurs may depend on the relative laxity of the gastrosplenic, gastrocolic,
and gastrohepatic ligaments. As the hiatal hernia becomes larger, two
types of volvulus may develop. Organoaxial volvulus (longitudinal axis)
occurs with movement of the greater curvature of the stomach anterior
to the lesser curvature. Mesenteric axial volvulus is less common and
occurs when the stomach rotates along its transverse axis.
When the GEJ cannot be reduced below the diaphragm, despite
extensive dissection in the mediastinum, then a shortened esophagus
is present. This phenomenon is believed to occur in patients with chronic
gastroesophageal reflux disease (GERD), with resultant transmural
inflammation and contraction of the esophageal tube.
CLINICAL PICTURE
Although small type 1 hiatal hernias may be asymptomatic, most patients
complain of typical and atypical symptoms of GERD. Heartburn is the
main symptom of GERD, but patients may also complain of acid reflux,
regurgitation of food, epigastric abdominal pain, dysphagia, odyno-
phagia, nausea, bloating, and belching. Atypical or extraesophageal
symptoms include noncardiac chest pain, choking, laryngitis, coughing,
wheezing, difficulty breathing, sore throat, hoarseness, asthma, and
dental erosions.
Symptoms of type 2 and 3 paraesophageal hernias differ from GERD
symptoms. Although the symptoms vary, most series describe dysphagia,
chest pain, and regurgitation as the most common. One series defined
the symptoms as regurgitation (77%), heartburn (60%), dysphagia
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Neil R. Floch
(60%), chest pain (52%), pulmonary problems (44%), nausea, and
vomiting (35%), hematemesis or hematochezia (17%), and early satiety
(8%). Asymptomatic patients may constitute 11% of the population,
and the hernia may be discovered on routine chest radiography or
endoscopy. Questioning may reveal the presence of symptoms in most
patients.
Dysphagia may result from twisting of the esophagus by a herniated
stomach. Chest pain may be confused with angina, resulting in emer-
gency cardiac evaluation with negative results. Dyspnea may be secondary
to loss of intrathoracic volume. Coughing may be a sign of aspiration,
which can develop into pneumonia or bronchitis.
Iron-deficiency anemia occurs in 38% of patients. Usually but rarely
is there evidence of gastrointestinal (GI) bleeding. Cameron ulcers or
mucosal ulcerations of the stomach, found in 5.2%, are a cause of
anemia. Ischemia and mucosal injury occur secondary to the friction of
the stomach moving through the esophageal hiatus during respiration.
Postprandial distress—defined as chest pain, shortness of breath,
nausea, and vomiting—occurs in 66% of patients. Eventually, as the
hernia enlarges, most patients have these symptoms. Conversely, as a
hernia enlarges, heartburn decreases. Heartburn is less common in type
3 than in type 1 hernias.
As many as 30% of patients will need emergency surgery for bleed-
ing, acute strangulation, gastric volvulus, or total obstruction. Surgery
is performed to treat perforation after strangulation with peritonitis,
but mortality is 17%. If gastric necrosis has developed, mortality may
reach 50%.
DIAGNOSIS
Most type 1 hiatal hernias are detected either by barium esophagraphy
or by upper endoscopy. Computed tomography (CT) may also detect
a hiatal hernia. Preferentially all patients should undergo esophageal
manometry to determine the presence of an associated motility disorder
before any surgical intervention. Specifically, achalasia should be
ruled out. Patients with ineffective esophageal motility (IEM) or sclero-
derma may benefit from surgery but should undergo a partial fundo-
plication. Determination of the presence of acid or bile reflux can be
performed with classic 24-hour pH testing, impedance testing, or the
Bravo technique.
Upright chest radiography may reveal an air-fluid level behind the
heart in 95% of patients. Nasogastric tube placement in the intrathoracic
stomach confirms the diagnosis. Paraesophageal hernia can also easily
be detected on CT. An upper GI series can establish the type of hiatal
hernia. In a series of 65 patients, 56 (86%) were found on barium
swallow or esophagogastroduodenoscopy (EGD) to have a type 3 para-
esophageal hernia. EGD will reveal a hiatal hernia best on retroflexion.
Nine (14%) had type 2 paraesophageal hernia. More than half of the
stomach was in the chest in 21% of patients.
61
62 SECTION I Esophagus

Congenital
short esophagus

Sliding
hernia

Peritoneal sac

Fig. 12.1  Type I: Sliding Hiatal Hernia.

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 CHAPTER 12  Sliding and Paraesophageal Hiatal Hernias Types 1, 2, and 3 63

Paraesophageal hernia

Peritoneal sac

Peritoneal sac

"Upside-down" stomach
(advanced paraesophageal hernia)

Fig. 12.2  Paraesophageal Hernias. (A) Type II. (B) Type III.

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64 SECTION I Esophagus
A herniated stomach can be intubated only by using EGD, a naso-
gastric tube, or manometry. When possible, manometry can assess
esophageal body motility, LES pressure, LES length, and total esophageal
length. Manometry may be possible in only approximately 50% of
patients. (Traditional manometry has been replaced by high-resolution
manometry [HRM] with esophageal pressure topography [EPT], as
described in Chapter 13.) At least 50% of patients with paraesophageal
hernias have a hypotensive LES. An incompetent LES was found in
56% to 67% of patients, with an average pressure of less than 6 mm
Hg. Short intraabdominal length of the LES combined with a sliding
hernia may also contribute to reflux.
The amplitude of peristaltic waves is reduced in 52% to 58% of
patients. Poor body motility can result in the delayed clearance of refluxed
acid; this requires partial fundoplication, although some authors advocate
the floppy Nissen procedure in this situation. A short esophagus may
be related to a mixed, or type 3, paraesophageal hernia and is believed
to result from injury to the esophageal wall secondary to stricturing
and fibrosis from reflux. Whether the short esophagus is a result or the
cause of paraesophageal herniation has yet to be determined.
Twenty-four-hour esophageal pH testing is not a diagnostic test for
a paraesophageal hernia but may be helpful in identifying associated
gastroesophageal reflux in 50% to 65% of patients.
TREATMENT AND MANAGEMENT
Repair of a small type 1 sliding hiatal hernia entails reduction of the
hernia sac from the chest and performing either a partial (Toupet) or
total (Nissen) fundoplication. If the fundus moves alongside the esopha-
gus, the hernia is then classified as paraesophageal. The most difficult
type 1 sliding hernias involve a shortened esophagus. When the GEJ
cannot be reduced easily 3 to 4 cm below the diaphragm, the technique
of extensive mediastinal dissection must be used. This involves dissect-
ing all lateral, anterior, and posterior attachments of the esophagus to
the mediastinum, taking care to avoid entering the pleura or disturbing
major vessels. Dissection may be necessary up to the level of the aortic
arch. GERD treatment or type 1 hiatal hernia repair results in at least
90% patient satisfaction rate.
Observation of paraesophageal hernias can result in emergency
complications such as incarceration, strangulation, perforation, splenic
vessel bleeding, and acute dilation of the herniated stomach in 20% of
patients. A cohort study concluded that watchful waiting is reasonable
for the initial management of patients with asymptomatic or minimally
symptomatic paraesophageal hernias. Asymptomatic patients at high
risk for morbidity after surgery may be observed. Nonsurgical manage-
ment resulted in 29% mortality, but this rate is now believed to be
lower. Asymptomatic patients have a lower risk for complications.
Symptoms indicate the need for elective repair. Elective surgery carries
a zero to 3% mortality rate. In comparison, emergency surgery results
in up to a 40% mortality rate.
Studies are indeterminate as to the best technique for repairing
paraesophageal hernias. Patients with comorbidities who undergo lapa-
roscopy may experience the low complication rate, short recovery, and
long-term results seen after open surgery.
Paraesophageal hernia is a surgical disease that cannot be ade-
quately treated medically. Symptoms of reflux may be reduced with
H2 blockers and PPIs, but the hernia cannot be fixed without surgery.
Paraesophageal hernia repair (PEHR) may, at the discretion of an expe-
rienced foregut surgeon, be performed by any of the following three
approaches: laparoscopic, open transabdominal, or transthoracic. It can
be accomplished with low mortality and morbidity with any of these
approaches. All three procedures are equal in resolving symptoms such
as acid reflux and dysphagia. Open PEHR has average morbidity of
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14%, an average mortality of 3%, and length of hospital stay of 3 to 10
days. Major complications include bowel obstruction and splenectomy.
The recurrence rate after laparotomy is 11%. Transthoracic PEHR is
advocated by some surgeons for patients who are obese, have short-
ened esophagus, have large or complex hiatal hernias, or have recurrent
hernias. The procedure has a higher morbidity and should therefore
be performed only for recurrences or in those patients who cannot be
approached through the abdomen. Thoracotomy results in 19% mor-
bidity and up to 25% mortality. Reoperation may be necessary in 5%
of patients.
Laparoscopy involves significantly lower rates of blood loss, intensive
care unit stay, ileus, hospital stay, and overall morbidity. Laparoscopy
is beneficial in the elderly population.
Failure to perform concomitant antireflux surgery results in post-
operative reflux in 20% to 40% of patients. Antireflux surgery may
improve motility in 50% of patients. Concomitant antireflux surgery
should be performed for the following reasons: (1) especially when
positive findings on 24-hour pH testing are found; (2) because destruc-
tion of the LES after surgical dissection of the hiatus predisposes to the
development of GERD if not already present; (3) because incompetence
of the LES is no longer masked by the paraesophageal hernia after it is
reduced; (4) because the fundoplication secures the stomach into the
abdominal cavity; (5) because there is minimal morbidity added to the
procedure; and (6) because emergency surgery may need to be performed
and thus preoperative testing cannot be performed.
Short esophagus has an overall incidence of 1.5%. Among patients
with paraesophageal hernias, 15% to 20% have short esophagus.
The diagnosis of short esophagus is made at surgery if the LES is
5 cm above the hiatus or if the esophagus is difficult to mobilize from
the mediastinum.
In the past, the Collis-Belsey procedure has been recommended to
treat short esophagus in patients with type 3 paraesophageal hernias.
Newer techniques rely on more aggressive dissection. First, the hernia
sac is reduced. Extensive dissection enables the esophagus to be mobi-
lized from the chest into the abdomen. Patients with short esophagus
who undergo laparoscopic transmediastinal dissection have a 90% success
rate for fundoplication, almost equal the rate for patients with normal
esophageal length (89%). The advent of laparoscopic transmediastinal
dissection has rendered the Collis gastroplasty less necessary.
Gastrostomy and anterior gastropexy should be considered for elderly
and debilitated patients who have many comorbidities and cannot tol-
erate extensive surgery. Both procedures secure the stomach to the
abdominal wall, thus preventing future herniation. Disadvantages are
the discomfort and inconvenience of a gastrostomy tube.
Alternatively, for severely debilitated patients, an endoscopic hernia
reduction with or without laparoscopy can be performed with a double
percutaneous endoscopic gastrostomy (PEG) tube placement to secure
the stomach in the abdomen temporarily. A formal laparoscopic PEHR
can be performed at a later time if the patient’s medical condition
improves.
If a primary crural closure is not possible, a tension-free mesh repair
may be indicated. Most recent reports promote a primary suture closure
of the muscle reinforced with an onlay of mesh that has a keyhole
opening stapled to the crura. A defect larger than 5 cm is usually reported
when mesh is used. Various prosthetic materials—including polyester
(Mersilene), polytetrafluoroethylene (PTFE), and polypropylene—have
been used for mesh. Along with these permanent mesh materials, mul-
tiple biologic materials have been used. All types of mesh have been
effective in randomized trials. A meta-analysis of four randomized trials
comparing mesh over primary repair with primary repair with sutures
alone demonstrated a 2% versus 9% reoperation rate and a 16% versus
27% recurrence rate with equal complications at 10%.
 CHAPTER 12  Sliding and Paraesophageal Hiatal Hernias Types 1, 2, and 3
COURSE AND PROGNOSIS
Immediately after surgery, patients should be treated with antiemetics
to prevent the tearing of sutures. A swallow of diatrizoate (Gastrografin)
is performed routinely on postoperative day one to confirm no leakage
and the stability and location of the fundoplication.
Complications may be divided into intraoperative, postoperative,
and late sequelae. Intraoperative complications occur in up to 17% of
patients. Esophageal and gastric perforations related to bougie usage,
tears, and lacerations occur in 11% of patients. Excessive bleeding may
occur after dissection, tearing of the short gastric vessels, or liver retrac-
tion. Vagal nerve injury is rare but may lead to gastric atony, delayed
gastric emptying, and bezoar formation.
Pleural entry and pneumothorax may occur in 14% of patients.
Rarely of clinical significance is pneumomediastinum or crepitus, which
resolves with no sequelae other than respiratory acidosis secondary to
carbon dioxide exposure or, rarely, pulmonary embolus.
The 3% conversion rate frequently reflects the inability to decrease
mediastinal contents caused by mediastinal scarring of a shortened
esophagus. Traumatic vessel injury is a common reason for conversion,
but other causes may be adhesions and difficulty with exposure. Exposure
may be limited in patients who are obese or who have hepatomegaly.
Postoperative complications occur in 3% to 28% of patients. The
most serious postoperative complications are pulmonary embolism,
myocardial infarction (heart attack), cardiac dysrhythmias, cerebrovas-
cular accident (stroke), and respiratory failure. Other conditions that
may develop are pneumonia or pleural effusion, congestive heart failure,
deep venous thrombosis, urinary retention, and superficial wound infec-
tions. Dysphagia is the most frequent postoperative problem. Dilation
may be required in 6% of patients. Over time, some fundoplications
slip, become undone, or migrate to the mediastinum. Postoperative
pain is usually limited to incisions, but patients may have left shoulder
pain caused by diaphragmatic irritation.
Reoperation rates range from zero to 9%. Early reoperation may be
necessary for recurrence of a hernia, fundoplication slippage, esophageal
or stomach perforation, or small-bowel obstruction. Dilation may be
necessary for patients with dysphagia after surgery.
Mortality rates range from zero to 5%. Frequently, patients have
gas-bloat syndrome, which includes bloating, abdominal gas, increased
flatus, uncontrolled flatus, belching, and abdominal discomfort. Patients
may also experience early satiety, pain after meals, and weight loss.
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65
Operative time averages from 1 to 3 hours. Most patients stay in
the hospital for 1 to 2 days. On average, patients return to normal
activities within 1 to 3 weeks. Displacement of the paraesophageal hernia
from the chest results in improved (15%–20%) pulmonary function.
On average follow-up at 1.5 years, 92% of patients are satisfied with
the surgical result.
Asymptomatic recurrence rates may be very high, but they range
only from zero to 32% when barium esophagraphy is used. Clini-
cally symptomatic recurrences are much lower, as indicated by the
zero to 9% reoperation rate. Most patients with recurrences undergo
surgery only if they have symptoms. Evaluation usually reveals a
sliding herniation of the wrap in about 80% of patients. Although a
recurrent paraesophageal hernia may occur, reoperation is not usually
necessary.
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