Hiatal hernia is a frequent pathology and its frequency of occurrence increases along with age. Four types are distinguished: sliding hiatal hernia, paraoesophageal hernia, mixed hiatal hernia and giant hiatal hernia. The first is the most frequent and is connected with reflux disease (1).

Patients with hiatal hernia present many different symptoms, such as thoracic pain, dyspnea, belching, heartburn, recurrent pneumonia, hoarseness, chronic cough, anemia caused by iron deficits. Non-specific symptoms are connected with the fact that patients are under control of different specialists and are treated due to different conditions such as asthma, COPD, circulatory failure, angina, ulcerous disease (2). The most frequently, patients present symptoms of gastroesophageal reflux and are treated conservatively with proton pump inhibitors.

Literature reports that hiatal hernia coexisting with GERD brings better treatment results, lower number of remissions, higher improvement of quality of life after laparoscopic Nissen fundoplication than after conservative treatment with proton pump inhibitors. Surgical treatment is necessary in case of sliding hiatal hernia with reflux disease and paraoesophageal hernia. However, perioperative risk should be considered for patients in advanced age and numerous co-morbidities when treatment with proton pomp inhibitors brings relief. In patients with non-symptomatic hiatal hernia, the operative risk should be compared with the risk of perioperative complications (3).

The first report on hiatal hernias has been published in 1853 by Bowditch (4). Hirsch in 1900, diagnosed hiatal hernia using X-ray (5). Akerlund in 1926 proposed the term hiatal hernia and classified its 3 types which are used until now (6).

The frequency of occurrence of hiatal hernia increases along with age. Actual frequency of occurrence of hiatal hernia may only be estimated due to the fact that it brings only mild or no symptoms, and diagnostic criteria may differ. Clinical estimations report that approximately 50-60% of patients over 50 years old suffer from hiatal hernia (7, 8). The frequency of occurrence of symptomatic cases of hiatal hernia is strictly connected with the recognition of gastroesophageal reflux disease (GERD) due to the fact that both those conditions are strongly correlated (9, 10). Approximately 9% of hiatal hernias are symptomatic. Precise frequency of treated cases of GERD in large populations is difficult to verify but specific indexes for Western countries is within 10-20% (11-13).

Sliding hiatal hernia (type I) are significantly more frequent and consist of 90-95% of cases, esophageal type (type II) consists of only 5% where LES remains below the diaphragm and the stomach is relocated to the thorax.

Hiatal hernias occur the most frequently in highly developed countries of Northern America and Western Europe, and the most rarely in African and Eastern populations (14, 15). Some authors suggest that predispositions for hiatal hernia development include insufficient amount of fiber and high sitting position during defecation (16, 17).

Hiatal hernia may be congenital or acquired. Among acquired hiatal hernias, traumatic and nontraumatic are distinguished. The most common types of hernia are acquired in non-traumatic manner. Nontraumatic acquired hernias are divided into four subtypes: sliding (type I) and paraoesophageal (type II). Mixed type with coexisting features of sliding and paraoesophageal hernia are also observed (type III). IV type of hiatal hernia is connected with short esophagus.

Sliding hiatal hernia is most common type of hiatal hernia. It occurs when the gastro-esophageal junction, along with the part of the stomach, migrates to the mediastinum through the esophagus (fig. 1). In the majority of patients with esophageal hernia, no symptoms are observed, in part of patients’ symptoms of reflux are visible. This type of hernia interferes with the anti-reflux barrier mechanisms in several ways. The lower esophageal sphincter (LES) relocates from an area with positive pressure inside the abdominal cavity to the area of low pressure in the thorax, which interferes with the activity of the sphincter. What is more, the relaxation of diaphragm crura reduces the anti-reflux barrier of the esophagus. The Hiss angle is lost in the diaphragmatic hernia, which causes higher risk of regurgitation of gastric contents. These changes, not only predispose to reflux of gastric contents to the esophagus, but also prolong the time of acid contact with the esophageal epithelium causing chronic esophagitis, metaplasia of the epithelium.

In the paraoesophageal hernia, broadened diaphragmatic hiatus allow to relocate the stomach fundus to the thorax, the gastro-esophageal junction stays below the diaphragm (fig. 2). Within the time, the part of the stomach and other abdominal organs moved to the thorax are enlarged. In this type of hernia, the anatomical Hiss angle remains unchanged, so there is no gastro-esophageal reflux (18).