Paraesophageal Hernia Repair
What the Examiner Expects
Repair of a paraesophageal hernia where the gastric fundus (Type II) or the entire stomach and other organs (Type III/IV) herniate through the hiatus alongside the esophagus. The examiner expects you to classify the hernia type, recognize that Type I (sliding) hernias are managed medically unless symptomatic GERD warrants fundoplication, and know that all symptomatic paraesophageal hernias should be repaired due to risk of volvulus, incarceration, and strangulation. The operative approach is laparoscopic: reduce the hernia, excise the sac, perform posterior crural closure, and add a fundoplication. If there is a short esophagus (< 2–3 cm of intra-abdominal esophagus), a Collis gastroplasty is needed to achieve adequate length.
Key Examiner Focus Points
- Type II (true paraesophageal), III (mixed), IV (with additional organ herniation)
- Surgical repair indicated for all symptomatic paraesophageal hernias
- Complete hernia sac excision, tension-free crural closure, and fundoplication
- Collis gastroplasty if short esophagus prevents tension-free intra-abdominal esophageal length
- Emergent repair for incarceration, obstruction, or gastric volvulus
Common Curveballs
Patient presents with acute epigastric pain, retching without vomiting, and inability to pass an NG tube
Borchardt's triad — gastric volvulus. This is a surgical emergency. Attempt endoscopic decompression; if it fails, proceed to emergent laparoscopic or open reduction, assess for gastric ischemia, repair the hernia, and perform gastropexy.
After reducing the hernia, the esophagus retracts and you cannot get 2–3 cm below the hiatus without tension
Short esophagus. Perform a Collis gastroplasty — use a stapler to create a neo-esophagus along the lesser curvature, then perform fundoplication around the neo-esophagus. Do NOT force a tension repair.
Crural defect is very large (> 5 cm) and tissues are attenuated
Consider biologic mesh reinforcement of the crural closure. Synthetic mesh is avoided due to erosion risk near the esophagus. Some surgeons perform relaxing diaphragmatic incisions as an alternative.
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