Parahiatal Hernia: An Elusive Diaphragmatic Defect Revealed Intraoperatively

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Background: Parahiatal hernia (PHH) is an exceptionally rare diaphragmatic defect located adjacent to the normal esophageal hiatus. Its clinical presentation often mimics that of paraesophageal hernia, making preoperative diagnosis challenging. Case Presentation: We report the case of a 69-year-old man with a one-year history of postprandial epigastric pain. Imaging studies suggested a mixed hiatal hernia with complete intrathoracic migration of the stomach. Laparoscopic exploration revealed a 4-cm left paraesophageal defect consistent with parahiatal hernia. The herniated stomach was reduced, and the defect was closed in a tension-free manner using interrupted sutures. Given the presence of gastroesophageal reflux and to minimize tension following left crus dissection, a Nissen-Rossetti fundoplication was performed. The postoperative course was uneventful, and the patient remained asymptomatic at the one-month follow-up. Discussion: PHH represents less than 0.2% of hiatal hernia repairs and is typically located lateral to the left phrenic pillar. Diagnosis is rarely established preoperatively due to its anatomical proximity to the esophageal hiatus and nonspecific symptoms. Optimal management involves minimally invasive reduction and primary closure of the defect. For large or tension repairs, mesh reinforcement—particularly with synthetic nonresorbable materials—reduces recurrence without increasing morbidity. Muscle-flap repair may serve as an alternative in selected cases. The decision to perform fundoplication should be individualized based on reflux symptoms and the stability of the hiatal complex. Conclusion: Awareness of PHH and its distinguishing radiologic and intraoperative features is crucial for accurate diagnosis and tailored surgical repair, minimizing recurrence and improving outcomes.

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