Hiatus Hernia

A hiatus hernia is the protrusion of part of the stomach (and sometimes other viscera) through the oesophageal hiatus of the diaphragm into the chest. It ranges from the common sliding type, closely linked to gastro-oesophageal reflux, to less common paraoesophageal types that can present with mechanical and obstructive complications.

Definition

A hiatus hernia is the displacement of the gastro-oesophageal junction and/or stomach through the diaphragmatic oesophageal hiatus into the posterior mediastinum; sliding (type I) hernias displace the junction axially, while paraoesophageal (types II to IV) hernias involve herniation of the gastric fundus or other organs alongside the oesophagus.

Scope

This topic covers the anatomy of the oesophageal hiatus, the standard classification of hiatus hernias (types I to IV), the relationship between sliding hiatus hernia and gastro-oesophageal reflux disease, and the principles of repair including hiatal closure and fundoplication. It is reference-educational and does not provide operative or treatment instructions.

Core questions

• How are hiatus hernias classified into types I to IV?
• How does a sliding hiatus hernia relate to gastro-oesophageal reflux?
• When are paraoesophageal hernias considered for repair?
• What are the principles of hiatal closure and fundoplication?

Key concepts

• Oesophageal hiatus of the diaphragm
• Sliding (type I) hiatus hernia
• Paraoesophageal (types II to IV) hernia
• Gastro-oesophageal junction displacement
• Gastro-oesophageal reflux disease association
• Hiatal closure (crural repair)
• Fundoplication

Mechanisms

Widening of the diaphragmatic oesophageal hiatus and laxity of the phreno-oesophageal membrane allow the gastro-oesophageal junction (sliding type) or the gastric fundus alongside the oesophagus (paraoesophageal types) to migrate into the chest. Sliding hernias disrupt the anti-reflux barrier and are associated with gastro-oesophageal reflux disease, while large paraoesophageal hernias carry a mechanical risk of obstruction or, rarely, gastric volvulus. Surgical management, as framed by guidelines, combines reduction of the hernia and closure of the crura with an anti-reflux fundoplication; randomized evidence compares anti-reflux surgery with medical acid suppression for reflux control.

Clinical relevance

Hiatus hernia is closely tied to reflux disease and to the field of foregut surgery, making its classification and physiology important for interpreting the relevant literature. This entry describes anatomy, classification, and how surgical and medical strategies are compared; it is educational reference material and not a basis for individual diagnostic or treatment decisions.

Epidemiology

Sliding hiatus hernia is common and increases in prevalence with age and obesity, and is frequently found in association with gastro-oesophageal reflux disease; paraoesophageal hernias are far less common but account for the mechanically complicated presentations, as outlined in the management guidelines.

History

The link between hiatus hernia and reflux was clarified through twentieth-century radiology and physiology, and surgical repair was transformed by the introduction of fundoplication and its later laparoscopic adaptation. Society guidelines and randomized trials such as LOTUS have since defined the comparative evidence on surgical versus medical management.

Debates

Surgery versus long-term medical therapy for reflux-associated hiatus hernia

Randomized data show laparoscopic anti-reflux surgery and optimized acid-suppression therapy can both control chronic reflux over years, so the choice weighs durability, side effects, and patient preference rather than clear superiority.

Management of asymptomatic paraoesophageal hernia

Whether large paraoesophageal hernias with few symptoms should be repaired electively or observed is debated, balancing the low annual risk of acute complications against operative risk.

Key figures

• Geoffrey Kohn
• Lars Lundell
• Jean-Paul Galmiche

Seminal works

• kohn-2013
• galmiche-2011

Frequently asked questions

What is the difference between a sliding and a paraoesophageal hiatus hernia?

In a sliding (type I) hernia the gastro-oesophageal junction itself moves up into the chest, whereas in a paraoesophageal (types II to IV) hernia the gastric fundus or other organs herniate alongside the oesophagus, sometimes with the junction in normal position.

Is a hiatus hernia the same as reflux disease?

No. A hiatus hernia is an anatomical displacement through the diaphragm, while gastro-oesophageal reflux is a symptom complex; sliding hiatus hernia is strongly associated with reflux but the two are distinct concepts.