Hiatal Hernia Surgery
A hiatal hernia occurs when the upper portion of the stomach pushes through the hiatus, an opening in the diaphragm through which the esophagus passes. The majority of hiatal hernias are asymptomatic, and patients do not even know they have them. Usually, they are found secondary to testing for another condition or even during surgery in the abdomen such as bariatric (weight loss) surgery.
There are four sub-types of hiatal hernia. Type one is a sliding hiatal hernia, while types two through four are varying forms of paraesophageal hernia. Sliding hiatal hernias, which account for 95% of all hiatal hernias, involve the stomach and esophagus pushing upward together. Typically, when pressure is relieved in the abdomen, the stomach drops back down into its normal place in the abdominal cavity. A paraesophageal hernia is more severe as the stomach pushes up into the chest and lodges itself next to the esophagus. Other abdominal structures including the large intestine and fat tissue can also push into the hernia sac. This can cause strangulation, which is an emergency situation that can be life threatening.
Smaller hiatal hernias typically caused fewer symptoms. However, as with all hernias, they are progressive which means they get worse over time. Larger hiatal hernias can cause significant symptoms including:
- Acid reflux
- Difficulty swallowing
- Pain in the chest
- Difficulty breathing and
- Bloody vomit or stool
Treatment for Hiatal Hernias
If lifestyle change, in the form of improved exercise, and medication therapy has not been successful in improving or eliminating the symptoms of gastroesophageal reflux disease, surgery may be considered to repair a hiatal hernia.
A hiatal hernia repair Is typically performed using sutures to close the defect. On rare occasions when the hiatal hernia is large enough, an absorbable or biologic mesh may be used to enhance the repair. Since hiatal hernias are most often found incidentally, they are often corrected during a primary bariatric surgery. In fact, most bariatric patients also suffer from hiatal hernias. Virtually all hiatal hernia repairs are performed laparoscopically with or without the use of a robot.
Paraesophageal hiatal hernias are considered to be at higher risk of complications and must be dealt with promptly. A Nissen fundoplication – the wrapping of the upper portion of the stomach around the lower portion of the esophagus – is the definitive treatment for this type of hiatal hernia.
Patients who are receiving a LINX reflux management device and who also have a hiatal hernia larger than 3 cm, will need to have the hiatal hernia repaired before the device is implanted.
Risks of Hiatal Hernia Surgery
Most of the risks associated with a hiatal hernia repair revolve around the risks of laparoscopic surgery in general and include reaction to anesthesia, infection, blood loss, pain, failure to completely resolve symptoms and in very rare cases, death. If the hiatal hernia repair is performed secondary to another procedure in the abdomen, you will be made aware of the combined risks by your surgeon. This is not a comprehensive list of risks of a hiatal hernia repair and only a consultation with your general surgeon can offer a complete picture of what your risks and considerations may be.