In the hospital, we often encounter such patients, most of whom are admitted with symptoms such as heartburn, acid reflux and retrosternal pain after eating, and a small number of them have sore throat, asthma and angina, but all of them are diagnosed with “esophageal hiatus hernia” without exception. What kind of disease is esophageal hiatus hernia? With this question in mind, let’s take a closer look at it. When it comes to hiatal hernia, we should first understand what is meant by hiatal hernia and the reasons for its formation. As we all know, human beings need to breathe to survive, and breathing is accomplished without the participation of muscles. There is an important muscle between the thoracic and abdominal cavities of the human body, which, with its contraction and relaxation, completes a complete breathing movement. In the center of the diaphragm there is a “fissure” through which the esophagus goes down to connect with the stomach, hence the name “esophageal fissure”. The hernia is formed mainly when the pressure in the abdominal cavity increases or when the structure around the esophageal hiatus is too relaxed, so that the organs of the abdominal cavity (in most cases the stomach) can enter the thoracic cavity through the esophageal hiatus, thus forming the “esophageal hiatus hernia” in medicine. There are two main causes of esophageal hiatus hernia, namely congenital and acquired factors. Congenital factors are mainly congenital developmental disorders in young patients, such as dysplasia of the diaphragmatic foot around the esophagus, which can be accompanied by a short esophagus, resulting in a large esophageal hiatus and weak tissue around the hiatus. Acquired ones are mainly induced by factors such as relaxation of the diaphragmatic esophageal fascia, peri-esophageal ligaments and increased intra-abdominal pressure. With further research, more and more scholars prefer that acquired factors are the main cause of the disease. Type I, also known as sliding hiatal hernia, is the most common and accounts for about 75%-90% of all hiatal hernia in clinical practice. In sliding hiatal hernia, the length of esophagus is normal, only the gastroesophageal junction and part of the gastric cavity enter the thoracic cavity with the enlarged hiatal hernia, which often appears when lying down and disappears when standing up. Type II paraesophageal hernia, paraesophageal hernia: it is less common, accounting for only 5% to 20% of hiatal hernias, and shows that a part of the stomach (gastric body or gastric sinus) enters the thoracic cavity through the widened and relaxed hiatal hernia in front of the left side of the esophagus, while the gastroesophageal junction is in a normal position. Type III is a mixed type of esophageal hiatal hernia, which is common to the first two types of hernia and has common features of the first two types of hernia. Type IV giant esophageal hiatal hernia can be considered as a result of the continued development of types II and III. The part of the stomach herniated into the thoracic cavity is more massive and can reach more than 1/3 of the stomach or even part of other organs such as omentum, colon and spleen, which is the most harmful and more complicated to treat, often requiring the use of patches. Clinically, patients with esophageal hiatal hernia have a variety of manifestations, but most patients still mainly have the clinical manifestations of esophageal reflux disease, which is commonly known as heartburn. For example, burning sensation, pain and reflux behind the sternum appear after eating, mostly at night when lying down, so that patients do not rest well and suffer; if reflux is prolonged, it can cause esophageal spasm and stricture, and even symptoms such as dysphagia after eating. In addition, if the hernia sac is embedded in the gastro-thoracic cavity and forms an obstruction, it can lead to decreased lung function, infarction and perforation of the embedded organ. Other rare symptoms include “angina pectoris” due to strain on the foot of the diaphragm, “pharyngitis” due to pharyngeal contracture stimulated by reflux, “bronchial asthma” due to reflux, and other rare symptoms. How to diagnose a hiatal hernia How to diagnose a hiatal hernia? The presence of the above clinical manifestations only proves the possible existence of a hiatal hernia, but its diagnosis needs to be supported by auxiliary tests. Generally speaking, the diagnosis of hiatal hernia includes medical history, clinical manifestations, physical examination, imaging (gastroscopy, upper gastrointestinal tract imaging), laboratory tests (24-hour esophageal PH test, lower esophageal pressure test), etc. The combined use of imaging and laboratory tests often increases the diagnostic compliance rate to more than 70%, while allowing an accurate assessment of the condition of the esophageal mucosa, the length of the esophagus, the motor status of the esophagus, the condition of acid reflux, the size of the hernia, and the movement and emptying of the stomach. This lays the foundation for the next step of treatment. The current treatment of esophageal hiatus hernia includes two main types of treatment: medical treatment and surgical treatment. The main principles of medical treatment are to eliminate the factors of hernia formation, to control gastroesophageal reflux and promote esophageal emptying, and to moderate or reduce the secretion of gastric acid. Therefore, the main drugs used for treatment include acid suppressants, gastric mucosa protectors and gastric motility drugs. However, for patients with esophageal hiatus hernia, medical treatment is only a symptomatic treatment that can relieve the patient’s pain, but with the progressive development of the hiatus hernia, surgical treatment will eventually be required. The main goals of surgical treatment are to restore the esophagogastric angle, treat the hernia sac, repair the enlarged esophageal hiatus, strengthen the tone of the lower esophageal sphincter, and prevent the occurrence of gastroesophageal reflux. In 1991, Dallemagne and Geagea first reported the use of laparoscopic techniques for the treatment of esophageal hiatal hernia and anti-reflux surgery, which achieved good results. Since then, laparoscopic treatment of esophageal hiatal hernia has been rapidly promoted. Laparoscopic treatment of esophageal hiatal hernia has been proven to be a safe and effective surgical procedure, especially in elderly people with a high incidence of esophageal hiatal hernia, where the advantages of laparoscopy, such as less trauma, faster recovery, less pain and better tolerance, are better reflected. In terms of surgical separation of anatomy, laparoscopy has the advantages of good field exposure, clear images, and is more suitable for precise operations. Therefore, laparoscopic fundoplication should be the preferred surgical approach for patients with surgical indications for esophageal hiatal hernia. The surgical indications for laparoscopic esophageal hiatal hernia repair mainly include: 1. The esophageal hiatal hernia is type I, combined with moderate or severe reflux esophagitis and poor medical treatment. 2. Patients with esophageal hiatal hernia of type II, type III, or giant esophageal hiatal hernia. 3.Patients with combined severe peptic esophagitis, esophageal stricture, bleeding, and Barrett’s esophagus. The principles of surgery are the same as those of open surgery, i.e., repair of esophageal hiatal hernia, removal of the hernia sac, and establishment of an anti-reflux barrier. We performed the operation using a five-hole method with the largest poke hole (3) of 10 mm and the smallest (2) of only 5 mm.