Clinical relevance of laparoscopically diagnosed hiatal hernia

Yves Van Nieuwenhove Æ Jeroen Sonck Æ Boudewijn De Waele ÆPeter Potvlieghe Æ Georges Delvaux Æ Patrick Haentjens

Received: 3 February 2008 / Accepted: 25 April 2008 / Published online: 20 May 2008

� Springer Science+Business Media, LLC 2008

Abstract

Background To determine the clinical relevance of a la-

paroscopically diagnosed hiatal hernia.

Methods Consecutive patients undergoing an elective

laparoscopy were prospectively recruited. We assessed

preoperative gastroesophageal reflux symptoms using a

validated score, and documented the presence or absence of

a hiatal hernia during laparoscopy.

Results Of the 95 evaluable patients, 42 (44%) had a

hiatal hernia. The mean age was 49.8 years. Logistic

regression analysis indicated that three features were sig-

nificantly and independently associated with hiatal hernia:

a higher reflux score (odds ratio [OR] 2.44; 95% confi-

dence interval [CI] 1.48-4.05; p \ 0.001), low body mass

index (BMI) (OR 0.83; 95% CI 0.70–0.98; p = 0.029), and

type of surgery (OR 0.34; 95% CI 0.14–0.92; p = 0.033).

The diagnostic accuracy of a reflux score of more than 2

was 81%, with a sensitivity, specificity, positive predictive

value, and negative predictive value of 76%, 85%, 80%,

and 82%, respectively. The likelihood ratio for a positive

result was 5.05.

Conclusion Hiatal hernia is common in this population of

surgical patients undergoing an elective laparoscopy.

Patients with reflux symptoms or a low BMI were more

likely to have a hiatal hernia. With a reflux score of more

than 2, the probability of finding a hiatal hernia during

laparoscopy is 80%.

Keywords Laparoscopy � Hiatal hernia �Gastroesopheageal reflux � Diagnosis

The yearly budget spent on proton pump inhibitors (PPIs)

in Belgium is as high as €153 million and consumes about

0.20% of Belgium’s gross domestic product. The larger

part of this medication is prescribed to patients with

chronic gastroesophageal reflux disease (GERD), which is

estimated to affect about 15–40% of the Western popula-

tion [1–3].

GERD is a multifactorial disease resulting from an

unbalance between lower esophageal sphincter (LES)

pressure, esophageal peristalsis, transient relaxations of the

LES, and gastric acid production. This can lead to the

inflammation of the esophageal mucosa caused by chronic

contact with aggressive gastric refluxates. During the 1960s

GERD was considered synonymous with hiatal hernia.

Thanks to technological innovations in the following years,

elegant instruments were developed to measure the pres-

sure in the different segments of the esophagus and it was

demonstrated that many GERD patients had a hypotensive

LES [4]. Thereafter, transient relaxations of the LES could

be measured and were held responsible for most of the

gastroesophageal reflux events [5]. The importance of the

hiatal hernia was recently rediscovered by the findings of

two independent papers indicating that a hiatal hernia not

only increases the frequency of having transient relaxations

of the LOS [6] but also increases the severity of reflux [7].

The problem with the diagnosis of hiatal hernia is that

there is no real standard diagnostic test to assess its

Y. Van Nieuwenhove (&) � J. Sonck � B. De Waele �G. Delvaux � P. Haentjens

Department of Surgery, Universitair Ziekenhuis Brussels, Vrije

Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium

e-mail: hlkvney@uzbrussel.be

P. Potvlieghe

Department of Surgery, Aalsters Stedelijk Ziekenhuis,

Merestraat 80, 9300 Aalst, Belgium

123

Surg Endosc (2009) 23:1093–1098

DOI 10.1007/s00464-008-9970-4

presence. Endoscopy is the most accurate means for the

diagnosis of esophagitis, but it significantly underestimates

the presence of a hiatal hernia when compared with radi-

ology [8]. Barium contrast studies are still considered as

the most accurate method of diagnosing a hiatal hernia, but

it remains virtually impossible to compare this test with in

vivo findings. During laparoscopic surgery, the surgeon is

in the position to assess the esophageal hiatus from within

the peritoneal cavity, and this with an increased intra-

abdominal pressure. In this study we examined the rele-

vance of a laparoscopically detected hiatal hernia in the

light of GERD symptoms in a population of patients

undergoing a laparoscopy for various reasons.

Patients and methods

Between April and July 2003, all consecutive patients who

were to undergo an elective laparoscopic intervention for

various reasons in our department of abdominal surgery

were recruited to participate in this prospective study. The

laparoscopic interventions were: cholecystectomies for

symptomatic gallstones, diagnostic explorations for right

quadrant pain with subsequent appendectomy, sigmoidec-

tomies for recurrent diverticulitis, and adjustable gastric

bandings for morbid obesity. The gastric bandings were

performed in patients between 18 and 65 years old with a

body mass index (BMI) of more than 35 kg/m2. We

excluded patients under 18 years old and pregnant women,

as well as patients with a history of gastroesophageal sur-

gery, gastroesophageal cancer or esophageal achalasia.

From 103 eligible patients, 8 patients were excluded during

the planned intervention because they had adhesions in the

upper abdomen. The study protocol stipulated that patients

were to be excluded when it was impossible to visualize the

hiatal region without adhesiolysis. Eventually, in 95

patients it was possible to evaluate the hiatal region.

Bodyweight and height were measured on admission.

Body mass index (BMI) was calculated by dividing the

patient’s weight (kg) by the square of the patient’s height

(m). All patients were subjected to a GERD Symptom

Score questionnaire by an independent interviewer (J.S.),

not being part of the surgical team. Permission to use the

GERD questionnaire was obtained from M. Anvari who

has validated the questionnaire for the assessment of

GERD symptoms previously [9]. This questionnaire scores

six different GERD symptoms based on their frequency (0,

never to 4, daily) and severity (0, none to 3, severe). The

evaluated symptoms were heartburn, retrosternal/epigastric

pain, regurgitation, dysphagia, epigastric fullness, and

coughing. The total score was the sum of the products of

frequency and severity scores of each individual symptom

and ranged between 0 and 72. If patients were on PPIs or

H2 blockers, the questions were asked referring to the

situation prior to the start of medication.

The study was approved by the local ethical committee

and informed consent was obtained from each patient

before entering the study.

Laparoscopic diagnosis of hiatal hernia

Anaesthesia was obtained following a standardized proto-

col. After induction with intravenous propofol (Diprivan�,

TCI) orotracheal intubation was carried out and inhalation

with desflurane in combination with a 50% oxygen–air

mixture was maintained. Muscle relaxation was induced

with succinylcholine followed by cisatracurium. Intermit-

tent doses of sufentanil or remifentanil were given when

needed in function of pain control.

The surgical team was blinded for the results of the GERD

score questionnaire. During laparoscopy and after insertion

of one 10-mm trocar to allow insertion of a 10-mm 25�angled laparoscope and at least one 5- or 10-mm trocar for an

extra grasper, a 15-mmHg pneumoperitoneum was deployed

and the patient was put in a 30� anti-Trendelenburg position.

Before the eventual insertion of a nasogastric tube, the left

lobe of the liver was gently retracted ventrally. It was then

possible to visualize the hiatal region and the presence or

absence of a hiatal hernia. It was agreed in the study protocol

that patients were to be excluded when it was impossible to

visualize the hiatal region without adhesiolysis.

There is no precise definition of a hiatal hernia, but for

the sake of standardization we chose to adapt the com-

monly used definition of a hiatal hernia as the sliding of the

gastric cardia in a caudo-cranial direction for more than

2 cm beyond the diaphragmatic crura [10]. This measure-

ment was possible by inserting the 2-cm-long legs of a

laparoscopic forceps along the cardia through the esopha-

geal hiatus. If no hernia was observed spontaneously, an

extra pressure was exerted on the abdominal wall during 5–

10 s to reach an intraperitoneal pressure of 30 mmHg.

After visualization of the hiatal region, the rest of the

procedure was carried out as planned.

Statistical analysis

Patient data were prospectively entered in a computerized

database and statistical analyses were performed using

SPSS 11 for MacOSX.

Clinical characteristics and GERD score were summa-

rized descriptively for the whole group, and for patients

stratified according to the presence or absence of a hiatal

hernia.

Differences between groups were assessed by the chi-

square test and Fisher exact test for categorical data and the

Student’s t test for continuous data.

1094 Surg Endosc (2009) 23:1093–1098

123

To determine the independent contribution of each

variable to the presence of a hiatal hernia, logistic regres-

sion analysis was used. The status of the esophageal hiatus

(presence or absence of a hiatal hernia) was used as the

dependent variable, and the clinical characteristics (age,

gender, BMI, type of surgery, use of PPIs, and GERD

score) as the independent variables.

The diagnostic performance of GERD score to dis-

criminate patients with hiatal hernia from patients without

hernia was explored by receiver operating characteristic

(ROC) curve analysis. The area under the ROC curve

(AUC) represents the probability that a test correctly dis-

criminates between patients with and those without hiatal

hernia, where 0.5 is chance discrimination and 1.0 is per-

fect discrimination. The optimal cut-off is chosen from the

graph. The best cut-off is that which maximizes the sum of

the sensitivity and specificity, which is the point nearest to

the top left-hand corner. Formally, this point corresponds

to the maximal value of the Youden index, which is simply

the sum of sensitivity + specificity – 1. Statistical indices

of diagnostic performance (sensitivity, specificity, accu-

racy, positive and negative likelihood ratios, and positive

and negative predictive values) and their corresponding

95% confidence intervals (CI) were computed with the

two-by-two table method using standard formulae.

Results

The overall mean age ± standard deviation (SD) was

49.8 ± 17.6 years and there were 25 men and 70 women

(Table 1). The mean overall GERD score was 2.64 (95%

CI 1.99–3.65).

Univariate analyses indicated that subjects with a lapa-

roscopically diagnosed hiatal hernia had a higher GERD

score (p \ 0.01), a higher BMI (p = 0.015), and were

older (p \ 0.01) than those where a hernia was not seen

(Table 1). Furthermore, the proportion of patients on PPIs

(p \ 0.01) and the types of interventions (p = 0.001) were

significantly different between subjects with and without a

hiatal hernia (Table 1).

Multivariate (logistic) regression analysis indicated that

only three features were significantly and independently

associated with hiatal hernia: a higher reflux score

(p \ 0.001), a low BMI (p = 0.029), and type of surgery

(p = 0.033). Hiatal hernia was not significantly associated

with either gender, age or the use of PPIs (Table 2).

The area under the ROC curve for the GERD score was

0.84 (95% CI 0.75–0.92, p \ 0.001, Fig. 1). The Youden test

resulted in a cutoff value of 2 for dichotomizing the contin-

uous GERD score, allowing the statistical indices of

diagnostic performance to be calculated (Table 3). A GERD

score value of more than 2 identified about 76% of patients

with hiatal hernia (sensitivity) and about 85% of subjects

without hiatal hernia (specificity). Of those subjects with a

GERD score value of more than 2, about 80% had hiatal

hernia (positive predictive value), whereas 82% of patients

with a GERD score value of more than 2 had no hiatal hernia

(negative predictive value). The likelihood ratio for a

Table 1 Clinical and operative characteristics for the whole group and for patients stratified for the presence or absence of a hiatal hernia

Total group (n = 95) No hernia (n = 53) Hernia (n = 42) p value*

Age in years (mean ± SD) 49.8 ± 17 42.9 ± 15.9 58.5 ± 15.8 \0.001

Gender (M/F) 25/70 11/42 14/28 0.203

BMI in kg/m2 (mean ± SD) 27.7 ± 7.2 29.0 ± 8.7 25.9 ± 4.3 0.015

PPI use (yes/no) 12/83 0/53 12/30 \0.001

GERD score (mean ± SD) 2.6 ± 3.8 0.5 ± 1.2 5.3 ± 4.4 \0.001

Laparoscopic interventions

Cholecystectomy, n (%) 46 (48.4) 19 (35.8) 27 (64.3) 0.001

Appendectomy, n (%) 24 (25.3) 16 (30.2) 8 (19.0)

Sigmoidectomy, n (%) 9 (9.5) 3 (5.7) 6 (20.0)

Adjustable gastric banding, n (%) 16 (16.8) 15 (28.3) 1 (2.4)

* Univariate analysis, no hernia group versus hernia group

BMI, body mass index; PPI, proton pump imhibitor; GERD, gastrooesophageal reflux disease score [9]

Table 2 Logistic regression analysis for the association between

clinical variables and the presence of a hiatal hernia

Variable Odds ratio 95% confidence interval p value

Age (decades) 1.22 0.81–1.84 0.34

Female gender 0.95 0.20–4.46 0.95

BMI 0.83 0.70–0.98 0.029

PPI use 52.7 0–7.19 e24 0.88

GERD score 2.44 1.48–4.05 0.001

Surgical procedure 0.34 0.14–0.92 0.033

BMI, body mass index; PPI, proton pump inhibitor; GERD, gas-

trooesophageal reflux disease score [9]

Surg Endosc (2009) 23:1093–1098 1095

123

positive result of 5.05 indicates that a GERD score value of

more than 2 is five times more likely in an individual with

hiatal hernia than in one without hiatal hernia.

Discussion

In this study, we observed a hiatal hernia during laparos-

copy in 44% of our patients, and we found that three

features were significantly and independently associated

with hiatal hernia: a higher reflux score, a low BMI, and the

type of surgery.

Our prevalence of hiatal hernia during planned laparo-

scopic surgery is much higher than in an autopsy study

showing only 8 hiatal hernias in 55 cadavers [11]. During

autopsy, an underestimation is likely to occur as it might

prove difficult to detect a small hiatal hernia when the

intra-abdominal pressure is neutralized after opening the

peritoneum. Our prevalence of hiatal hernia is also higher

than the 239 hiatal hernias detected in 1000 subjects during

endoscopy in a large population-based Swedish study [3].

Several reports, however, provide evidence that endoscopy

does not give a correct estimation of the real incidence of

hiatal hernia [8, 12].

We determined the discriminatory value of the GERD

reflux score for differentiating hiatal hernia based on ROC

curve analysis. An area under the curve of more than 0.80

indicates a diagnostic test to be effective. Our findings also

indicate that, above a defined cutoff value of 2 of the

GERD reflux score, patients have a fivefold increased

likelihood of having a hiatal hernia. In other words, 80% of

patients suffering from mild heartburn more than once a

week are likely to have a hiatal hernia.

Traditionally, the association of a hiatal hernia and

obesity has led to the advice of weight reduction for

patients suffering from GERD. Several recent meta-anal-

yses have demonstrated that there is a significant

association between obesity and GERD symptoms [13, 14].

These meta-analyses make several reservations when it

concerns the association of obesity and the presence of a

hiatal hernia. Only four out of the nine individual studies

included in these meta-analyses specifically examined the

relation between esophagitis, hiatal hernia, and BMI. Two

individual studies were able to show a distinct association

between BMI and the combination of reflux symptoms with

a hiatal hernia [15, 16]. One individual study [17] dem-

onstrated a significant relation between BMI and the

isolated presence of a hiatal hernia, while another failed to

demonstrate such a relation [18]. In all these individual

studies, however, a hiatal hernia was not identified and, in

those that did, the criteria for identifying and measuring

hiatal hernia may not have been used uniformly.

Our own data even suggest a decreased risk of hiatal

hernia in obese subjects. This remarkable finding should be

handled with caution, mainly because the relation between

BMI and hiatal hernia was not the primary objective of our

study. Furthermore, given the small sample size of our

study, we acknowledge the potential for selection bias. For

instance, the presence of GERD in morbidly obese subjects

has long been a relative contraindication for performing a

laparoscopic adjustable gastric banding, which can account

for the a priori but unintended exclusion of patients with a

hiatal hernia in this subset of patients [19].

The type of surgery was a significant and independent

factor for the presence of a hiatal hernia, even though, for

Fig. 1 Receiver operating characteristic (ROC) curve of the GERD

score in patients with and without a laparoscopically diagnosed hiatal

hernia (AUC = 0.84, 95% CI = 0.75–0.92, p \ 0.001). GERD,

gastro-oesophageal reflux disease; ROC, receiver operating charac-

teristic curve; AUC, area under the curve

Table 3 Statistical indices of diagnostic performance for GERD

score (cutoff value = 2 based on ROC) and the presence of a hiatal

hernia

Point estimate 95% confidence interval

Sensitivity 0.76 0.63–0.89

Specificity 0.85 0.75–0.95

Positive likelihood ratio 5.05 2.61–9.77

Negative likelihood ratio 0.28 0.16–0.49

Positive predictive value 0.80 0.68–0.92

Negative predictive value 0.82 0.70–0.92

Diagnostic accuracy 0.81 0.70–0.92

GERD, gastrooesophageal reflux disease [9]; ROC, receiver operating

charcteristic curve

1096 Surg Endosc (2009) 23:1093–1098

123

example, patients undergoing gastric banding were

younger than those undergoing sigmoidectomy or chole-

cystectomy, confirming the usefulness of an approach

based on multivariate (logistic) regression analysis. The

type of surgery has an impact on the presence of a hiatal

hernia presumably because it already characterizes a spe-

cific patient profile. Our findings support the assumption of

‘‘Saint’s triad,’’ according to which cholelithiasic patients

would have an increased prevalence of hiatal hernia [20].

Methodological strengths of our study include its pro-

spective design, the consecutive recruitment of unselected

patients planned to undergo laparoscopic surgery (not

excluding younger adults or very old individuals), a high

proportion of eligible patients being enrolled, and the use

of a well-validated instrument to measure gastroesophageal

reflux symptoms [9].

The problem with the diagnosis of hiatal hernia is that

there is no real standard diagnostic test to assess its pres-

ence. Barium contrast studies are still considered as the

most accurate method of diagnosing a hiatal hernia, but it

remains virtually impossible to compare this test with in

vivo findings. During laparoscopic surgery, on the other

hand, the surgeon is in the position to assess the esophageal

hiatus from within the peritoneal cavity, helped by an

increased intra-abdominal pressure.

The question remains of whether a laparoscopic visu-

alization of a hiatal hernia is the most precise way to

diagnose this. In other words: is the laparoscopic diagnosis

of a hiatal hernia the gold standard? The effects of muscle

relaxants, positive ventilation, and pneumoperitoneum

might be confounding factors. Hernias, however, be they

hiatal, ventral or inguinal, are not a problem of muscles but

are breaches in the abdominal wall. The main difference is

that a ventral or inguinal hernia can be diagnosed by

clinical body surface examination, which cannot be done

for a hiatal hernia. Moreover, an inguinal or ventral hernia

will slide through the abdominal wall during a Valsalva

maneuver pushed by the increased intraperitoneal pressure,

while the sliding of a hiatal hernia from abdomen to thorax

will be neutralized by the equally high intrathoracic pres-

sure. Muscle relaxants probably do not have any effect on

the presence of a hernia. Just as in laparoscopic inguinal

and ventral hernia repair, the hernias remain unchanged

whether the patient is curarized or not. In our series, all

patients were routinely curarized and more than half of

patients did not have a hiatal hernia, leaving no grounds to

assume its effect on the hiatal hernia. Normal intra-

abdominal pressures lie between 0 and 5 mmHg. The

working pressure commonly used in laparoscopy is

15 mmHg, but is still less than the intra-abdominal pres-

sures of more than 60 mmHg which can be measured

during laughing, coughing or sneezing. In this study we

have increased the intra-abdominal pressures to 30 mmHg

to detect the hiatal hernias, but for security reasons we did

not pass beyond this level. Overall, we do acknowledge

that the laparoscopic inspection of the hiatal region is too

invasive to be used as a diagnostic tool in routine day-to-

day clinical practice, but it is certainly a physiological

means of having an in vivo diagnosis of a hiatal hernia and

might thus be used as the gold standard for clinical research

purposes in patients undergoing a laparoscopy.

Despite its prospective design, the current study also has

some limitations related to its observational nature, in par-

ticular the potential for selection bias. The current study

included consecutive patients for which a laparoscopic sur-

gical procedure was needed. In doing so, there was, for

example, an imbalance in the proportion of patients scheduled

for laparoscopic gastric banding. As already indicated,

patients undergoing gastric banding were younger than those

undergoing sigmoidectomy or cholecystectomy, which might

also have confounded the results. We therefore conducted a

logistic regression analysis to determine the independent

contribution of each characteristic to the presence of a hiatal

hernia. Using this approach the type of surgery was confirmed

to act as an independent factor on the presence of a hiatal

hernia, while age was not. More specifically, there was a much

higher proportion of patients undergoing a cholecystectomy in

the group of patients with a hiatal hernia, a feature which

actually confirms the existence of ‘‘Saint’s triad’’ in which

gallstones, hiatal hernia, and diverticular disease share a

common predisposing factor [20]. Finally, laparoscopy may

underestimate the presence of hiatal hernia due to the peri-

esophageal and epiphrenic fat concealing a hernia in obese

subjects. In the current study such an underestimation is very

unlikely, as in our hospital, during placement of a gastric

banding, the hepatogastric ligament is routinely opened,

allowing direct visualization of the base of the crus and the

more retro-esophageal hiatal defect.

In conclusion, a hiatal hernia was observed in almost

half of a population of surgical patients scheduled to

undergo a laparoscopic procedure. Patients with reflux

symptoms or a low BMI were significantly more likely to

present with a hiatal hernia on laparoscopy. When a patient

has a reflux score of more than 2, there is an 80% proba-

bility of finding a hiatal hernia during laparoscopy. To our

knowledge, this is the first study examining the clinical

relevance of a hiatal hernia diagnosed in vivo by laparos-

copy. Furthermore, this study adds basic knowledge to

recent insights that the hiatal hernia is actually of far

greater importance in GERD than we assume [10].

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