Hiatal Hernia

Treat as a full stomach - The barrier between stomach and pharynx is mechanically incompetent, so a fasting interval does not buy you the protection it normally would. Plan an RSI, have suction on the field before you push the drug, and extubate awake.

Size the risk by hernia type - A type 1 sliding hernia in a patient whose reflux is controlled is a different problem from a giant hernia holding 30% or more of the stomach in the chest. The large ones and the paraesophageal ones retain food and secretions that no amount of fasting clears.

History that tells you which one you have - Ask about heartburn, dysphagia, early satiety, chest pain after meals, and nocturnal cough or asthma symptoms. Regurgitation of undigested food points to retention above the hernia rather than simple reflux, and extra-esophageal symptoms mark disease progression.

Check a hemoglobin - Large hiatal hernias erode the gastric mucosa at the level of the diaphragm (Cameron lesions) and bleed occultly, producing chronic iron-deficiency anemia. Get a CBC preoperatively rather than assuming the pallor is nothing; these lesions are often missed on the first endoscopy.

Look at the imaging that already exists - The upper GI series or barium swallow shows where the GE junction sits, the size of the defect, and how the stomach is oriented; high-resolution manometry reports lower esophageal sphincter function. Both are routinely done before repair, so read them rather than guessing at how much stomach is in the chest.

Gastric volvulus is a surgical emergency - A paraesophageal hernia can rotate the fundus and present as gastric volvulus. That patient arrives obstructed, vomiting, and unresuscitated, not booked for an elective fundoplication — resuscitate and secure the airway on that footing.

Large hernias compromise the lungs - Patients with a big intrathoracic stomach report respiratory symptoms and may have reduced air entry at the left base. Expect less reserve at induction and less room for the lung on the side the hernia occupies.

Watch for pneumothorax during hiatal dissection - Pleural injury is common in esophageal and hiatal surgery; the resulting pneumomediastinum usually resolves within 24 hours without sequelae, but tension pneumothorax occurs in 1% to 2%. A sudden rise in peak airway pressure with desaturation during the mediastinal dissection is that until proven otherwise.

Passing the bougie - A Nissen fundoplication is calibrated over a 52 French bougie so the wrap is not too tight. Pass it slowly and only while the surgeon is watching from inside — esophageal and gastric injury complicates about 1% of these repairs.

Know the complication profile - Reported complications after repair include gastric perforation, bleeding, aspiration, wound breakdown, and adverse cardiac events. Major bleeding occurs in about 2%. Elective paraesophageal repair carries roughly 1.5% mortality, which is why asymptomatic patients are increasingly left alone.

Emergence and recovery - The reflux barrier is no better in PACU than it was at induction, and enhanced recovery pathways restart oral fluids almost immediately. Extubate with the airway protected and sit the patient up.

A hiatal hernia is herniation of the stomach — or occasionally another abdominal organ — through the esophageal hiatus of the diaphragm. Four types are described. Type 1, the sliding hernia, accounts for roughly 95%: laxity of the phrenoesophageal ligament lets the gastroesophageal (GE) junction migrate into the posterior mediastinum, leaving too little intra-abdominal esophagus for the sphincter mechanism to work. Types 2 through 4 are true paraesophageal hernias, in which stomach — and in type 4 another organ, most often colon — rolls up alongside the esophagus. Anything that raises intra-abdominal pressure drives it: obesity, pregnancy, chronic constipation, COPD. Prevalence climbs with age; roughly 55% to 60% of people over 50 have one, though only about 9% have symptoms.

The anesthetic problem is the anatomy itself — stomach sitting above the diaphragm behind a mechanically defective barrier.