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5 things you should know about paraesophageal hernias – Chapter 2
Posted in Lectures on 4 July 2019

Victor Turrado-Rodriguez
Dulce Momblán


As stated in the previous chapter, the fact that paraesophageal hernia is an anatomic abnormality makes surgical restoration of the normal anatomy the only effective treatment. Patients with obstructive symptoms, bleeding or complications of gastroesophageal reflux disease associated with paraesophageal hernias should undergo surgical repair because they are the group at risk of developing life-threatening complications requiring emergency surgery. Watch and wait is the ideal strategy for patients with asymptomatic hernias.

Historical evolution

Although posttraumatic and congenital diaphragmatic hernias were described as early as the 16th century by several authors such as Ambroise Paré, Giovanni Battista Morgagni and Vincent Alexandre Bochdalek, hiatal hernia was seldom described in surgical literature. What is considered to be the first report of a type II hiatal hernia was given in 1853 by Henry Ingersoll Bowditch.

The recognition of hiatal hernia as a common anatomical abnormality had to wait until the advent of radiography. Walter Cannon, Albert Moser, Moritz Benedikt, Hirsch, and Eppinger, were the pioneers in hiatal hernia diagnosis at the beginning of the 20th century. Ake Akerlund proposed the term hiatal hernia in 1926.

“Diaphragmatic hernia through the esophageal hiatus may properly be termed hiatus hernia. They are most often true nontraumatic hernias and can be classified into 3 groups: a) hiatus hernias with congenitally shortened esophagus (thoracic stomach), b) paraesophageal hernias, c) hernias not included in a or b.” 

Ake Akerlund

The first attempts to treat hiatal hernias were made in 1919 by Angelo Soresi. He was followed by Stuart Harrington of the Mayo Clinic who presented his experience with 27 patients in a paper published in 1928.

In 1950, Richard Sweet  from the Massachusetts General Hospital described the transthoracic approach.

The second half of the 20th century shifted the focus from the anatomical defect to the functional physiological alteration. Phillip Allison and Norman Barrett established that reflux esophagitis and its complications were the physiological consequences of anatomical abnormalities.

“To summarize my views about the rationale of operations to cure reflux esophagitis, I believe that the hernia should be reduced because its presence permits reflux; the esophageal hiatus may sometimes require diminishing in size in the hopes that this maneuver will help to prevent a recurrence of the hernia; the esophagogastric angle should be reconstituted by fixing the cardia below the diaphragm and so allowing the fundus of the stomach to balloon up under the dome.”

Norman Barrett

It was in the midst of the physiological revolution that Rudolph Nissen (1955) and Ronald Belsey (1967) described the procedures that are used by most surgeons in the 21st century.

Another milestone in hiatal hernia repair was the description of the Collis procedure by J. Leigh Collis in 1957. Although his goal was to avoid complicated resectional procedures for frail patients, when the Collis procedure was combined with the Belsey procedure (Henderson and Pearson, Toronto, 1976) or with the Nissen procedure (Orringer and Sloan, Ann Arbor, 1974), it yielded excellent results.

In 1967, Lucius Hill reported the 8-year follow-up of the procedure that bears his name. In the same decade, in Europe, J Dor and Andre Toupet described two different techniques for partial fundoplication in order to decrease the risk of dysphagia that had been described after Nissen fundoplication.

Principles of the surgical procedure

Independently of the surgical approach (transthoracic, transabdominal, open, laparoscopic, thoracoscopic), the main principles of hiatal hernia repair should be maintained.

  • Reduction of the hernia content into the abdominal cavity.
  • Dissection and sac excision.
  • Correct repositioning of the esophagogastric junction.
  • Dissection of the diaphragmatic pillars.
  • Crural repair.
  • Fundoplication.

Reduction of the hernia content and sac excision

The dissection should start once the hernia sac has been identified. Attempts to reduce the content before the sac has been clearly identified should be avoided. The extrasaccular approach facilitates hernia reduction, mediastinal dissection, and sac excision, and allows for rapid and accurate identification of the anatomical structures (mediastinum, vagus nerve, esophagus, etc.) The extrasaccular approach has been reported to reduce the risk of conversion from 40% to 9%, and it also allows for sac excision, which has been reported to decrease the rate of early recurrence. 

Esophageal mobilization

The esophagus should be mobilized in order to achieve 2-3 cm of tension-free esophagus in an infradiaphragmatic position. Usually a high mediastinal dissection is necessary to achieve this goal. Fibrotic changes in the esophageal wall and long-standing hernias may increase the fixation of the esophagus or may decrease its length, making it difficult to reposition the esophagogastric junction into the abdomen. In these cases, an esophageal lengthening procedure may be necessary (Collis gastroplasty).


Primary cruroplasty with non-absorbable sutures was the standard practice for many years. Nonetheless, recurrence rates of up to 60% created the need for a different approach, which resulted in the reinforced repair. Initially it was performed with pledgets that buttressed the primary suture. However, most reinforced repairs currently use some kind of mesh. The indications for mesh repair and the outcomes of the reinforced cruroplasty are still controversial and will be the focus of chapter 4 of this series on hiatal hernias.

Rationale for fundoplication

Extensive dissection and alteration of the antireflux barrier function during hiatal hernia repair predispose to postoperative reflux. Reports show an increase in postoperative reflux in patients without fundoplication (53%) vs 17% in patients with fundoplication, de novo abnormal acid exposure in up to 37% of patients and esophagitis in 28%. The fundoplication may help stabilize the stomach below the diaphragm and thus reduce the risk of recurrence. Different techniques for fundoplication will be described in the next chapter of this series.


With the data currently available, gastropexy should be considered an additional procedure and not an essential step in the treatment of hiatal hernias, as no difference in recurrence rates has been reported compared to no-gastropexy hiatal hernia repair.