Hiatal Hernia of Stomach and Lesser Omentum in a Cadaver: Is It a Type III or IV?

Abstract

Hiatal hernias, protrusions of abdominal viscera through the esophageal hiatus, are classified into four types. Types I and II involve ascent of the stomach without affecting the gastroesophageal junction. Types III and IV involve the gastroesophageal junction. Type IV specifically may have stomach as well as other abdominal organ involvement, such as pancreas or omentum. Among these types, type IV is the most complex and rare form, accounting for only 0.1% of all cases of hiatal hernias. This report presents a case of a type IV hiatal hernia involving the lesser omentum and a significant portion of the stomach in an 86-year-old male cadaver with a history of mediastinal surgery. To our knowledge, this presentation in a cadaver has not previously been reported in the literature. This case highlights classification inconsistencies in the literature, particularly regarding type IV hiatal hernias. It is unclear given the current classification system, whether this presentation would be considered a type III or type IV hiatal hernia as it fits both criteria and there are several interpretations of the criteria of a type IV hiatal hernia. Inconsistencies in the classification system may impede standardization of care. This report highlights the need for a more precise classification system that better accounts for anatomical changes and clinical presentation.

Keywords: aneurysm; giant hiatal hernia; hiatal hernia; hiatal hernia classification; lesser omentum; paraesophageal; type iv.

Figure 1. Anterior to posterior view of the thoracic cavity with the heart and lungs resected.

The dashed line indicates the delineation between the tissue masses. Red arrows indicate lesser omentum. Blue arrows indicate the lateral margin of the gastric fundus.

Figure 2. Anterior to posterior view of the thoracic cavity. A portion of the diaphragm is resected to further visualize the hiatal hernia.

The red arrows indicate dissected margins of the lesser omentum. The blue arrows indicate the lateral margins of the gastric fundus. The white dashed line demonstrates where the esophageal hiatus resided.