The current state of hiatal hernia management

The current management of a hiatal hernia varies widely across practices, and finding a clear consensus continues to prove difficult. Surgical specialty, surgeon-specific training, and the variety of ways a hiatal hernia may present are among the various factors that cause confusion. Today, there is no surgical or medical specialty specifically dedicated to the management of this type of hernia. Currently, thoracic surgeons, general surgeons, bariatric surgeons, and foregut surgeons all share in the management and treatment of a hiatal hernia. With multiple specialties from many different backgrounds/training/experiences it can be assumed that some personal bias becomes involved in the management of a hiatal hernia. The hiatal hernia itself varies widely, they don’t present with the same symptoms, they don’t have the same dimensions, and they range from acute to chronic in nature. Presentation of these hernias is continually varying, comprised of either acute or chronic symptoms as well as anatomical variations. The role of the diaphragmatic hiatus is also increasingly recognized as being critical in the management of this condition. Understanding and properly addressing this anatomical abnormality is paramount and increased knowledge has led to improved outcomes.

Examining the progression of hiatal hernia management brings us through a timeline where all aspects of surgery have been traversed. Initially, large invasive transthoracic surgery was the standard, but now a minimally invasive transhiatal approach has predominated. Hospital protocols, including short hospital stays, and enhanced recovery protocols, have resulted in better subjective and objective outcomes. Preoperative workups have become recognized as essential and increasingly sophisticated with the introduction of a wide array of technology and skill sets. Image guided surgery as well as endoscopy has enhanced our ability to provide the best patient experience possible with precise surgical approaches and detail-oriented techniques. Experts have advanced the field of hiatal hernia management through research and evidenced based medicine enabling them to better be able to predict outcomes and manage patient expectations.

Many surgeons are faced with the challenges of treating diseases of the esophagus and will undoubtedly encounter the difficulties of managing a hiatal hernia throughout their careers. This text was created to cover all aspects of the management of hiatal hernias by experts in the field of esophageal diseases.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery for the series “Hiatal Hernia”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales-2019-hh-20). The series “Hiatal Hernia” was commissioned by the editorial office without any funding or sponsorship. Dr. Steven G. Leeds served as the unpaid Guest Editor of the series. Dr. Lee L. Swanstrom served as the unpaid Guest Editor of the series. Dr. Leeds reports other from Ethicon, other from Boston Scientific, outside the submitted work. Both authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

Steven G. Leeds

Lee L. Swanström