Hiatal Hernia Type 2 (Rolling)

Type II paraesophageal hiatal hernia is characterized by herniation of the gastric fundus into the mediastinum while the gastroesophageal junction remains relatively fixed below the diaphragm. Unlike sliding hernias, reflux symptoms may be minimal, and the clinical significance lies in the risk of volvulus, incarceration, and strangulation. Surgical repair focuses on meticulous mediastinal dissection to fully reduce the herniated stomach and mobilize the esophagus. Adequate esophageal mobilization is essential to achieve at least 2–3 cm of tension-free intra-abdominal esophagus. Complete excision of the hernia sac and careful preservation of the vagal trunks are key technical steps. Hiatal closure with a secure cruroplasty restores the diaphragmatic anatomy and prevents recurrence. Fundoplication, when performed, should only follow confirmation that esophageal length and hiatal geometry have been properly re-established.