hiatus hernia (HH)

Last edited 02/2018 and last reviewed 06/2021

Hiatus hernia is the herniation of an abdominal organ into the thoracic cavity, usually the stomach, through a widening of the oesophageal hiatus in the diaphragm.

Two main types are recognised:

• sliding or axial hiatus hernia – 85-95% of hiatus hernias - this is a direct herniation through the oesophageal hiatus
• paraoesophageal or rolling hiatus hernia – 5-15% - the herniation occurs due to the abdominal organ pushing up beside the oesophagus

Depending on the subdivision of para-esophageal hiatal hernias, a more comprehensive classification has been proposed which divides hiatus hernia into four types:

• type I    - sliding hiatal hernia
• type II  - classic form of para-oesophageal hernia
• type III - mixture of type I and II hiatal hernia
• type IV - herniation of abdominal structures other than the stomach (spleen, colon, pancreas, etc.) (2)

Type II-IV belongs to the para oesophageal hernia group with type III being the most common (more than 90%) and type II the least common (2).
Rarely patients may present with a giant hiatal hernia, defined by a hernia that includes at least 30% of the stomach in the thorax.

• majority are type III hernia with a sliding and paraesophageal component
• a third of giant paraesophageal hernias are associated scoliosis (1,3).

Reference:

• (1) Roman S, Kahrilas PJ. The diagnosis and management of hiatus hernia. BMJ. 2014;349:g6154
• (2) Kohn GP et al. Guidelines for the management of hiatal hernia. Surg Endosc. 2013;27(12):4409-28
• (3) Mitiek MO, Andrade RS.  Giant hiatal hernia . Ann Thorac Surg. 2010;89(6):S2168-73.