Introduction: Hiatal hernias have long been classified according to basic anatomical description of sac contents and gastroesophageal (GE) junction location. This system, simple in its construct, does not often provide useful information for the clinician. This is especially the case as the majority of paraesophageal hiatal hernias are classified as Type III despite their great variability in presentation and anatomy.
Methods: 15 patients with paraesophageal hiatal hernias were included in this analysis. All patients were evaluated with pre-operative CT scans, EGD, and esophageal manometry. All were repaired laparoscopically. CT scans were reconstructed in 3-dimensions employing a unique protocol with semi-automatic segmentation. The resulting 3-dimensional anatomatical models of the hernias were compared to intra-operative videos of the external anatomy and to EGD images of the intralumenal anatomy. Pre-operative esophageal manometry was used to localize the lower esophageal sphincter. In addition to crural repair of the hernia itself, surgical adjuncts included the use of buttressing mesh, fundoplication, gastrostomy, and collis gastroplasty.
Results: Reconstructed CT scans demonstrated a population of hernias with significant variability in the above characteristics despite all being described as Type III. Our multi-modal approach to studying hiatal hernias provides significantly more information than the current classification system. This includes the location and orientation of the hiatal defect, the sac contents, the geometric conformation of the stomach itself, and the relative coordinates of landmarks such as the spleen, liver, aorta, and spine.
Conclusions: Reconstructed 3-dimensional imaging of hiatal hernias permits the description of hernia anatomy in a manner not previously possible and demonstrates the inadequacy of present classification, encumbered by its overwhelming frequency of Type III hernias. This technology provides descriptive and analog metrics that allow for a wealth of data, paving the way for the development of a new, more sophisticated, more useful categorization approach - one that serves as a basis for our proposed new system for hiatal hernia classification.