Flexible endoscopy and hiatal hernias

Flexible endoscopic evaluation of the esophagus and stomach is a vital element of upper gastrointestinal surgery. Preoperatively, it allows for first-hand visualization of the pharyngeal, laryngeal, esophageal, gastric, and duodenal mucosa. Furthermore, endoscopy allows assessment of anatomic pathology that may influence operative decisions such as the presence of stricture, esophagitis, Barrett’s esophagus, hiatal hernias, or other anatomic variables. Flexible endoscopy is also vitally important in aiding with intra-operative quality control. For example, it is used to assess adequacy of intraoperative esophageal length, snugness of hiatal repair, symmetry of antireflux procedures, or for ruling out leaks. Finally, flexible endoscopy is indispensable in the management of both early and late complications resulting from upper gastrointestinal surgery, such as for hiatal hernia repairs or for antireflux surgery. Examples include esophageal dilations for postoperative dysphagia, endoscopic diversion with esophageal stents, endoscopic drainage procedures, and more. In summary, flexible endoscopy performs an irreplaceable role in all three phases of surgical foregut treatment and, as such, should ideally be performed by every operating foregut surgeon. This review article focuses on the use of flexible endoscopy in determining Hill grade, the diagnosis and evaluation of hiatal hernias, assessing recurrent hiatal hernias and herniated fundoplications, and the use of endoscopy in acute gastric volvulus and strangulation.