Diaphragmatic hiatal hernias. Recognizing and treating the major types.

The pathophysiology and treatment of herniations through the esophageal hiatus remain controversial. For the majority of patients with a sliding hiatal hernia, medical treatment is preferred. Antireflux surgical techniques are reserved for those who fail medical treatment or have specific complications. A paraesophageal hernia may be life-threatening and requires surgical correction when diagnosed. Definitive surgical treatment consists of reduction of the hernia, excision of the sac, and partial closure of the widened hiatus anterior to the esophagogastric junction. Temporary gastrostomy is also advisable. A few patients have mixtures of the two types of hernia, and only those with incompetence of the lower esophageal sphincter require an antireflux procedure.