Hiatus Hernia Surgery

What is a Hiatus Hernia?

A hiatus hernia, or hiatal hernia, occurs when the normal opening in the diaphragm for the oesophagus becomes stretched and enlarged. This allows the upper part of the stomach to slide up into the chest. This causes the one-way valve between the oesophagus and stomach to become faulty and commonly causes gastric reflux or heartburn.


Types of Hiatus Hernia

There are two main types of hiatus hernia.


Sliding Hiatus Hernia

This is the most common type. It occurs when the junction between the oesophagus and the upper part of the stomach moves up through the oesophageal opening in the diaphragm into the chest cavity. The herniated portion of the stomach can slide back and forth, into and out of the chest.


Rolling Hiatus Hernia

This is sometimes called a para-oesophageal hernia. In this case, part of the stomach bulges into the chest through the weakest part of the diaphragm, which is the oesophageal opening. The junction of the oesophagus and stomach stays within the abdomen, and the top part of the stomach (the fundus) bulges into the chest cavity. This type of hernia normally remains in one place, sitting next to the oesophagus, and does not move in or out when you swallow.


Symptoms of a Hiatus Hernia

Most people are not troubled by their hiatus hernia. Still, if reflux of the stomach's acid contents occurs (gastro-oesophageal reflux), you may experience heartburn, a painful burning sensation in the chest.


Sudden regurgitation of acid fluid into the mouth can occur, especially when you lie down or bend forward. These symptoms are a problem when you go to bed and can wake you up.


Other symptoms include:

  • belching
  • pain swallowing hot fluids
  • a feeling of food sticking in the oesophagus
  • Rarely, excruciating abdominal pain occurs when the blood supply is cut off to that part of the stomach that has protruded into the chest.
  • Nausea, vomiting, and loss of appetite indicate an intestinal obstruction.


Treatment for General Symptoms

General guidelines for treating heartburn and oesophagitis (inflammation of the oesophagus) are:

  • Avoid (or use only in moderation) foods and substances that increase the reflux of acid into the oesophagus, such as nicotine (cigarettes), caffeine, chocolate, fatty foods, peppermint, alcohol, spearmint
  • Eat smaller, more frequent meals and do not eat within 2-3 hours of bedtime.
  • Avoid bending, stooping, abdominal exercises, tight belts, and girdles, all of which increase abdominal pressure and cause reflux.
  • If overweight, lose weight. Obesity also increases abdominal pressure.
  • Prescription medications.
  • Elevate the head of the bed 8 to 10 inches by putting pillows or a wedge under the upper part of the mattress. Gravity then helps keep stomach acid out of the oesophagus while sleeping.


What is Hiatus Hernia Surgery?

Hiatus hernia surgery refers to the surgical intervention to correct a hiatus hernia. A hiatus hernia occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. The surgical procedure involves repositioning the herniated stomach and repairing the diaphragmatic opening to restore the normal anatomy.


Who is Suitable for Hiatus Hernia Surgery?

The mere presence of a hiatus hernia is not a reason for surgery. Hiatus hernia surgery is typically recommended for individuals who experience severe symptoms or complications related to their hiatus hernia. Suitable candidates for surgery may include those with recurrent acid reflux, chronic heartburn, difficulty swallowing, or complications such as Barrett's oesophagus or oesophageal ulcers.


Benefits of Hiatus Hernia Surgery

Hiatus hernia surgery offers several potential benefits, including:

  • Symptom Relief: Surgery aims to alleviate symptoms associated with a hiatus hernia, such as acid reflux, heartburn, chest pain, and difficulty swallowing.
  • Improved Quality of Life: By addressing the underlying hernia, surgery can improve an individual's overall quality of life by reducing or eliminating the need for medication and providing long-term relief from symptoms.
  • Prevention of Complications: Hiatus hernias can lead to complications like esophagitis, ulcers, bleeding, and strictures. Surgery helps prevent these complications and their associated risks.


Types of Hiatus Hernia Surgery

There are different types of hiatus hernia surgery procedures available. The choice of procedure depends on factors such as the size and type of hernia, the patient's overall health, and the surgeon's expertise. Common types of hiatus hernia surgery include:

  • Nissen Fundoplication: This is the most common type of surgery performed for hiatus hernia repair. It involves wrapping the upper part of the stomach (fundus) around the lower oesophagus to strengthen the lower oesophageal sphincter and prevent acid reflux.
  • Toupet Fundoplication: A partial wrap procedure that addresses the hernia while preserving the ability to swallow effectively. It involves wrapping only a portion of the stomach around the lower oesophagus.


Laparoscopic Hiatus Hernia Repair

Normally, surgery to repair a hiatus hernia is done laparoscopically. This involves five small cuts in the abdomen, using the operating telescope (laparoscope) to return the stomach to the abdomen and reduce the size of the defect in the diaphragm.


Risks of Laparoscopic Hiatus Hernia Repair

All operations share some risks of laparoscopic hernia repair, but these risks rarely occur. They include heart attack, stroke, a clot in the lungs (pulmonary embolism), significant bleeding, infection and injury to the bowel.  Some risks are specific to laparoscopic hiatus hernia repair, which include:

  • About 1% of hernia repair patients will require revision surgery for a recurrent hernia
  • There can be an injury to the spleen.
  • Sometimes, the hernia cannot be repaired with the laparoscope, and an open repair is necessary. 
  • Occasionally, patients have difficulty swallowing after the operation. 
  • Bloating and discomfort from gas buildup may occur because the person cannot burp.
  • Excess gas.


Preparation Before Hiatus Hernia Surgery

Before undergoing hiatus hernia surgery, certain steps need to be taken:

  • Consultation and Evaluation: Consult a healthcare professional specialising in hernia surgery. They will evaluate your symptoms, perform diagnostic tests, and determine if surgery is appropriate.
  • Medical Preparation: Your doctor may provide specific instructions regarding medications to take or avoid leading up to the surgery. It's important to follow these instructions diligently.
  • Preoperative Testing: Depending on your medical history and the severity of your hernia, your doctor may request pre-operative tests such as an upper endoscopy or imaging studies to gather more information.


Hiatus Hernia Surgery Procedure

The surgical procedure for hiatus hernia repair typically involves the following steps:

  • Anaesthesia: You will be given anaesthesia to ensure you are comfortable and pain-free during the surgery. Your surgeon will determine the type of anaesthesia (general or local).
  • Surgical Approach: Hiatus hernia surgery can be performed using open or minimally invasive techniques such as laparoscopy. The surgeon will choose the most suitable approach based on individual factors.
  • Hernia Repair: The surgeon will reposition the herniated stomach back into the abdominal cavity and repair the opening in the diaphragm. This may involve sutures or the use of surgical mesh to reinforce the repair.


What to Expect After Hiatus Hernia Surgery?

After hiatus hernia surgery, several aspects need to be considered:

  • Hospital Stay: The length of the hospital stay varies but is typically short. You will be monitored for a brief period to ensure a smooth recovery. You can go home a few days after the operation and take a puree diet once comfortable. 
  • Recovery Diet: Your doctor will provide specific dietary guidelines for recovery. This may include initially consuming a soft or liquid diet and gradually reintroducing solid foods.
  • Pain Management: You may experience some post-operative discomfort, which can be managed with prescribed pain medications as your surgeon recommends.
  • Activity Restrictions: Your surgeon will provide instructions regarding activity restrictions, including lifting limitations and restrictions on strenuous activities. It's crucial to follow these guidelines to facilitate proper healing.


Hiatus Hernia Surgery Care Plan

  • Try not to drink too much for the first 24 hours. 
  • Stay away from driving for at least two days. 
  • Do not partake in heavy lifting (nothing heavier than a bucket of water) or strenuous exercise for six weeks. 
  • After one week - you can remove your dressings.
  • After two weeks - you should be able to return to work.
  • Schedule a postoperative appointment four weeks after the operation. 


Hiatus Hernia Surgery Prognosis

The prognosis for hiatus hernia surgery is generally favourable. Most individuals experience a significant improvement in symptoms and quality of life. However, individual outcomes may vary, and adherence to post-operative care instructions and lifestyle modifications are crucial for long-term success.


Hiatus Hernia Surgery Risks

As with any surgical procedure, hiatus hernia surgery carries risks and potential complications, including infection, bleeding, adverse reactions to anaesthesia, damage to surrounding structures, or hernia recurrence.

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