Definition & Overview
A hiatal hernia repair is a surgical procedure used to treat a hernia that has formed in the hiatus, an opening in the diaphragm through which the oesophagus passes before it meets the stomach. A hernia forms when an internal organ pushes outwards and into an area where it should not be. A hiatal hernia can be caused by obesity, pregnancy, old age, or the thinning of the phrenoesophageal membrane.
Hiatal hernias occur in two types, namely sliding and paraesophageal. A sliding hernia, the more common of the two, forms when the stomach and a part of the oesophagus slide up and push through the hiatus. In a paraesophageal hernia, a portion of the stomach pushes through the hiatus so that it lies next to the oesophagus, while the latter stays in its proper place. When this happens, the barrier between the oesophagus and the stomach becomes disrupted making the stomach acid to reflux back up the oesophagus.
Although this type of hernia is quite rare, there is a risk that the stomach will become strangled or lose its blood supply. This is why many patients consider surgery to have their hiatal hernia repaired.
Who Should Undergo and Expected Results
A hiatal hernia repair is highly recommended for those with a paraesophageal hernia, which is the less common but more serious type of hernia. This increases the risk of the stomach losing its blood supply as it squeezes through the hiatal opening. Patients also face an increased risk of pneumonia, or chronic lung inflammation, due primarily to the gastric acids that go back up the oesophagus. The condition may also lead to oesophageal stricture, or when the hiatal opening narrows.
Surgery is an important part of treatment for this condition and is especially important for patients whose hernias are very large, such that almost half of the stomach is already in the chest. Some symptoms that may signify the need for a surgical intervention include chest pain, abdominal pain, vomiting and nausea, and the inability to pass gas or have a bowel movement.
A hiatal hernia can also cause gastroesophageal reflux disease (GERD) symptoms, including heartburn and reflux. Since hiatal hernias frequently cause GERD, the procedure to repair a hernia is also sometimes known as anti-reflux surgery.
On the other hand, if a patient suffers from a sliding hernia but does not present with symptoms, surgery is rarely necessary. However, if the patient suffers from some symptoms and medical therapy is not working or is causing some side effects, surgery may also be an option. Likewise, patients who respond well to medications but no longer want to continue taking GERD medications for an extended period may also consider surgery.
A hiatal hernia repair is now more commonly performed using laparoscopy. This minimally invasive method of repairing a hernia allows patients to recover from their condition faster and to resume normal activities within a week after the surgery. They are expected to achieve full recovery within two to three weeks, as long as they avoid strenuous activities, heavy lifting, and hard labour for up to three months.
Most hiatal hernia repair procedures are effective in putting the misplaced part of the stomach back in its proper place. However, the surgery does not guarantee against future recurrences, so other medical procedures may be considered.
How is the Procedure Performed?
As focus shifts from open surgery to minimally invasive laparoscopic surgery, a hiatal hernia repair can now be performed without the need for a large incision and with minimal blood loss. In fact, nowadays, the laparoscopic surgery used to treat GERD and hiatal hernias is one of the most commonly performed surgical operations.
During a laparoscopic hiatal hernia surgery, the surgeon makes a few 5-10 mm incisions in the abdomen where a laparoscope and other surgical instruments are inserted. Using the laparoscope to obtain a view of the internal organs inside the patient’s abdomen, the surgeon performs the surgery with the help of the other surgical instruments.
To repair a hiatal hernia, the surgeon simply pulls the protruding portion of the stomach back into the abdomen. Some surgeons also wrap the top part of the stomach, called the fundus, around the lower oesophagus in a procedure called fundoplication. This is sometimes combined with hiatal hernia repair and is highly effective in preventing recurrences.
Possible Risks and Complications
The surgery to repair hiatal hernias is associated with the following complications:
- Difficulty swallowing
- Abdominal bloating
- Inability to belch or vomit
- Abdominal stricture
Some studies also show that a large number of patients who underwent the surgery required long-term medical therapy for ongoing heartburn for an average of 10 years. These complications occur more commonly in patients who responded to heartburn medications poorly prior to the surgery. This may mean that such patients have other existing medical problems aside from GERD and hiatal hernia.
There is also a risk that the surgery will not be effective. There is a 1 to 2 percent risk of the patient experiencing worse symptoms after the procedure. Thus, doctors perform a lot of important diagnostic tests prior to the operation to ensure proper patient selection and raise the patient’s chances of receiving successful treatment.
Kohn GP, Price RR, Demeester SR, Zehetner J, Muensterer OJ, Awad ZT, Mittal SK, Richardson WS, Stefanidis D, Fanelli RD. “Guidelines for the management of hiatal hernia.” Society of American Gastrointestinal and Endoscopic Surgeons. https://www.sages.org/publications/guidelines/guidelines-for-the-management-of-hiatal-hernia/
Flood CA. “Clinical features in the management of esophageal hiatal hernia.” JAMA. 1960; 172(4):314-319. http://jamanetwork.com/journals/jama/article-abstract/327453
Hoffman RF, Cruze K, Byron FX. “Symptomatic hiatus hernia.” JAMA. 1959; 169(2):119-123. http://jamanetwork.com/journals/jama/article-abstract/325220