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A paraesophageal hernia is a type of hiatal hernia. A hernia happens when a portion of fatty tissue or organ pushes through the muscular wall that usually contains it. A hiatal hernia is when a piece of the stomach bulges through the thoracic diaphragm and into the chest cavity. This usually involves just a portion of the stomach, but in certain cases, the entire stomach migrates into the thoracic cavity.
The thoracic diaphragm, more commonly and simply called the diaphragm, is a sheet-like muscle that separates the abdominal cavity from the thoracic, or chest, cavity and helps to contract and expand the thoracic cavity during respiration. During a paraesophageal hernia, the stomach, an integral organ in the process of digestion, protrudes through a normally occurring hole in the diaphragm. This hole, called the diaphragmatic hiatus, is located at roughly the level of the tenth vertebrae, counting from the head to tail, through which the esophagus passes. The esophagus is a muscular, tube-like organ that passes food from the pharynx to the stomach.
When a hiatal hernia occurs without a traumatic cause, it may fall into one of two categories: a paraesophageal hernia, also called a rolling-type hiatal hernia, or a sliding hernia. A sliding hernia, the more common of the two types, occurs when the gastrointestinal junction, the sphincter between the esophagus and stomach, and a top portion of the stomach protrude through the diaphragmatic hiatus. The herniated tissue, which is usually small, may then slide in and out of the thoracic cavity.
During a paraesophageal hernia, the fundus, or the rounded, anterior portion of the stomach, pushes through the esophageal hole in the diaphragm while the gastrointestinal junction stays beneath the diaphragm. This causes the stomach to rotate, or “roll,” counter-clockwise and may become lodged above the diaphragm, to the side of the esophagus. Often, patients with a paraesophageal hernia will not present with acid reflux, as the position of the sphincter between the stomach and esophagus remains unchanged. Though many patients are asymptomatic, a paraesophageal hernia may cause severe chest pain that does not respond to antacids, stomach pain, vomiting or heaving, nausea, indigestion, or difficulty swallowing.
A paraesophageal hernia can be a major health issue if the hernia becomes incarcerated or strangulated. Incarceration occurs when the herniated tissue becomes stuck in the protruded position and is undergoing pressure. Strangulation occurs when the blood supply to the herniated tissue is cut off, causing the death of the tissue. If there is risk of either of these two complications arising, the patient will undergo surgery to push the stomach back into place and reinforce the diaphragmatic hiatus. An incarcerated or strangulated paraesophageal hernia needs immediate surgical repair.
Typically, the surgery is performed laparoscopically. During this type of procedure, the surgeon makes small incisions into the abdomen through which to insert the surgical instruments. A laparoscope, a thin, tube-like device with a camera at one end, is inserted into one of the incisions so that the doctor may see without conducting open surgery, allowing for less scarring, bleeding, and a shorter recovery period. The doctor inserts instruments into the other incisions to reposition the stomach back below the diaphragm and strengthen the diaphragmatic hiatus.