A hiatal hernia occurs when the upper part of the stomach pushes up through the diaphragm’s small opening, called the hiatus, and into the chest cavity. This often results in the backward flow of stomach acid, known as gastroesophageal reflux disease (GERD). While many small hiatal hernias are managed with medication and lifestyle changes, surgery is typically reserved for patients whose symptoms are severe and do not respond to medical therapy. It is also recommended for cases involving complications, such as the risk of the stomach becoming twisted or strangulated, or for very large hernias, particularly paraesophageal types.
Surgical Approaches to Repair
The process of fixing a hiatal hernia begins with the method a surgeon uses to gain access to the abdominal and chest cavities. The most common approach today is the minimally invasive laparoscopic repair, which involves making several small incisions in the abdomen. Through these cuts, the surgeon inserts specialized instruments and a laparoscope, a thin tube equipped with a camera, to visualize the operative field.
Laparoscopic surgery offers the benefits of reduced postoperative pain, minimal scarring, and a quicker recovery compared to traditional open surgery. A variation of this technique is the robotic-assisted repair, which also uses small incisions but employs a robotic system controlled by the surgeon. The robotic platform provides enhanced three-dimensional visualization and instruments that mimic the flexibility of a human wrist.
The traditional method, known as open repair or laparotomy, requires a single, larger incision across the abdomen. This approach is now less common and is reserved for patients with complicated hernias, extensive internal scarring from prior surgeries, or in emergency situations. The specific approach chosen depends on factors like the size and type of the hernia and the patient’s overall health status.
Essential Steps of the Hernia Fix
Once surgical access is established, the first step is hernia reduction, which involves pulling the stomach and any other herniated organs back into the abdomen. The surgeon then dissects and removes the hernia sac, the tissue that pushed through the diaphragm, to mobilize the stomach and lower esophagus. Adequate mobilization ensures a sufficient length remains below the diaphragm without tension, preventing recurrence.
The next step is the hiatal closure, or crural repair. The two muscular pillars of the diaphragm, called the crura, are brought together and closed with strong, non-absorbable sutures, typically placed behind the esophagus. For large defects or recurrent hernias, a piece of surgical mesh may be placed over the sutured area to reinforce the repair.
The final part of the fix is the fundoplication, a procedure designed to strengthen the valve preventing stomach contents from refluxing into the esophagus. This involves wrapping the top part of the stomach, called the fundus, around the lower esophagus and stitching it in place. A Nissen fundoplication is a complete 360-degree wrap, while a Toupet fundoplication is a partial wrap, typically 270 degrees. The choice between a full or partial wrap depends on the patient’s esophageal function, with a partial wrap sometimes used to reduce the risk of post-operative difficulty swallowing.
Immediate Post-Surgical Recovery
The period immediately following hiatal hernia repair focuses on managing discomfort. Patients undergoing a laparoscopic procedure usually remain in the hospital for a short time, often between one and three days. Pain management addresses both the small incisions and a common temporary discomfort: shoulder pain, which is caused by residual carbon dioxide gas used to inflate the abdomen during the procedure.
A dietary progression is necessary to protect the fundoplication wrap from stress. Patients typically begin with a clear liquid diet on the day of surgery, advancing to full liquids the following day, including items like pureed soups and shakes. This liquid phase lasts for a few days before a gradual transition to a soft, mushy, or pureed diet begins for the next two to three weeks. This modified diet minimizes the effort required for swallowing, avoiding foods that could put pressure on the repair.
Temporary restrictions on physical activity prevent any sudden increase in intra-abdominal pressure that could compromise the repair. While patients are encouraged to walk soon after surgery, they must avoid heavy lifting, straining, or strenuous exercise, usually for four to six weeks. Patients must also avoid carbonated beverages, which can cause bloating and strain.
Maintaining the Repair Long-Term
Long-term success after hiatal hernia surgery relies on the patient’s commitment to specific lifestyle adjustments. Maintaining a healthy body weight is important, as excess weight increases pressure within the abdomen, contributing to the potential recurrence of the hernia. Patients should also avoid activities that involve excessive straining or lifting, which can place undue stress on the diaphragm repair.
Dietary habits must be adjusted, even after the initial soft-food phase is complete, focusing on eating smaller, more frequent meals and chewing food slowly and thoroughly. Avoiding known reflux triggers, such as highly acidic, spicy, or fatty foods, helps reduce the likelihood of symptoms returning. Patients should not lie down immediately after eating, waiting at least two hours to prevent acid from backing up into the esophagus.
Regular follow-up appointments with the surgeon or a gastroenterologist are an important part of long-term care to monitor for any return of symptoms. A hiatal hernia can recur, with some studies indicating that an anatomical recurrence may be seen on imaging in a percentage of patients over time. Even if a recurrence is detected, it may not cause symptoms, and surgical re-intervention is only considered if the patient experiences severe or persistent issues.