Surgery for Hiatal Hernia
A hiatal hernia is a condition in which a portion of the stomach protrudes upward into the chest, through an opening in the diaphragm. The diaphragm is the sheet of muscle that separates the chest from the abdomen. Your diaphragm normally has a small opening (hiatus) that allows your food tube (esophagus) to pass through on its way to connect to your stomach. Normally, your lower esophagus meets your upper stomach in the abdomen. However, the stomach can push up through this opening and cause a hiatal hernia.
Hiatal hernias occur when the muscle tissue surrounding this opening becomes weak, and the upper part of your stomach bulges up through the diaphragm into your chest cavity. Increasing age, obesity, and smoking are known risk factors in adults.
Hiatal hernias are very common, especially in people over 50 years old. This condition may cause reflux (backflow) of gastric acid from the stomach into the esophagus.
In most cases, a small hiatal hernia doesn’t cause problems, and you may never know you have a hiatal hernia unless your doctor discovers it when checking for another condition. But a large hiatal hernia can allow food and acid to back up into your esophagus, leading to heartburn and chest pain. Sometimes the stomach can get stuck in the chest leading to pain and vomiting. Self-care measures or medications can usually relieve these symptoms, although a very large hiatal hernia sometimes requires surgery.
Types of Hernias
There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus): In a sliding hiatal hernia, the lower esophagus and upper part of the stomach that connects to the esophagus both slide up into the chest through the hiatus. This is the more common type of hernia.
A paraesophageal hernia is less common, but is more cause for concern. In a paraesophageal hernia, the lower esophagus and upper part of the stomach that connects to the stomach stay in their normal locations, but another part of the stomach squeezes through the hiatus, landing next to the esophagus. Although you can have this type of hernia without any symptoms, the danger is that the stomach can become “strangulated,” or have its blood supply shut off, if it is not pulled down into the abdomen.
- Injury to the area
- An inherited weakness in the surrounding muscles
- Being born with an unusually large hiatus
- Persistent and intense pressure on the surrounding muscles, such as when coughing, vomiting, or straining during a bowel movement or while lifting heavy objects
- A decrease in the size of the abdominal cavity
Small hiatal hernias rarely cause symptoms — pain and discomfort are usually due to the reflux of gastric acid, air, or bile. Reflux happens more easily when there is a hiatal hernia, although a hiatal hernia is not the only cause of reflux
- Larger hiatal hernias can cause signs and symptoms such as:
- Chest pain
- Heartburn, worse when bending over or lying down
- Swallowing difficulty
- Regurgitation of Food
- Early Satiety (getting full quickly)
- Pain in the abdomen
Sometimes the stomach may become acutely stuck in the chest, which can lead to gangrene and perforation of the stomach. This is much more common in paraesophageal hernias. In these cases, an emergent operation is necessary.
Tests to Diagnose a Hiatal Hernia
A hiatal hernia is often discovered during a test or procedure to determine the cause of heartburn or chest or upper abdominal pain, such as:
An X-ray of the upper digestive tract (Upper GI or UGI). During an UGI, you drink a chalky liquid containing barium that coats your upper digestive tract. This provides a clear silhouette of your esophagus, stomach and the upper part of your small intestine (duodenum) on an X-ray.
Endoscopy (Using a scope to see inside your digestive tract). During an endoscopy exam, your doctor passes a thin, flexible tube equipped with a light and video camera (endoscope) down your throat and into your esophagus and stomach to check for inflammation.
Most people with a hiatal hernia don’t experience any signs or symptoms, and don’t need treatment. If signs and symptoms occur, treatment may be required, which can include medication or surgery.
Reducing the backflow of stomach contents into the esophagus (gastroesophageal reflux) will relieve pain. Medications that neutralize stomach acidity, decrease acid production, or strengthen the lower esophageal sphincter (the muscle that prevents acid from backing up into the esophagus) may be prescribed.
- Other measures to reduce reflux symptoms include:
- Avoiding large or heavy meals
- Not lying down or bending over immediately after a meal
- Reducing weight and not smoking
If these measures fail to control symptoms, or complications occur, surgical repair of the hernia may be necessary.
Surgery to repair a Hiatal Hernia
In a small number of cases, a hiatal hernia may require surgery. Surgery is generally reserved for emergency situations, symptoms not related to heartburn such as frequent regurgitation, pain, and difficulty eating and for people who aren’t helped by medications to relieve heartburn and acid reflux.
An operation for a hiatal hernia involves brining your stomach back down into your abdomen from the chest and repairing the hole in your diaphragm. A mesh is usually placed over the repaired hole in the diaphragm to create a stronger repair and prevent recurrence. In most cases, the surgery is performed laparoscopically, through several small incisions in your abdomen. A camera is inserted through one of the incisions and the operation is performed on a video screen. Most symptoms are alleviated with treatment.
Other Surgical Details
The operation to repair a hiatal hernia generally takes approximately 2 hours and requires an overnight stay in the hospital. Most people leave the hospital the next day.
Patients generally return to work an average of 3 to 7 days after surgery, depending on their pain and level of discomfort.
A clear liquid diet will be required for approximately 3 to 5 days after surgery. Clear liquids consist of broth, flat soda, water, or juice. If after 3-5 days clear liquids are tolerated well, the diet will be advanced to a soft diet. A soft diet consists of foods that are easy to chew and swallow such as foods softened by cooking or mashing, canned or soft-cooked fruits and vegetables, or moist, tender meats, fish, and poultry . If a soft diet is tolerated for three weeks, then a regular diet will be begun.
It is common to get full quickly when eating and occasionally feel bloated after surgery. Some patients may have some dysphagia, or difficulty swallowing after surgery. These symptoms usually improve within a few weeks.
Complications of Surgery
Laparoscopic Hiatal Hernia Repair is a surgical procedure with inherent risks. These risks are real but occur fairly infrequently (<1%). Some, but not all risks, are listed below:
- Pneumothorax (“dropped lung”)
- Perforation of the esophagus