A hiatal hernia occurs when a portion of the stomach protrudes upward through the diaphragm, the muscular wall separating the chest from the abdomen. While many people with a hiatal hernia experience no symptoms or manage them effectively with medication, surgical repair offers a viable solution for persistent or severe cases. This surgical intervention aims to correct the anatomical displacement and alleviate associated discomfort.
When Surgical Intervention is Considered
Surgery for a hiatal hernia is typically considered when conservative treatments, such as dietary adjustments, antacids, or other lifestyle modifications, fail to adequately control symptoms. Severe or persistent symptoms often prompt surgical evaluation. These can include unrelenting acid reflux, also known as gastroesophageal reflux disease (GERD), which does not respond to medication, difficulty swallowing (dysphagia), chest pain, or respiratory issues.
Immediate surgical intervention becomes necessary for serious complications. These complications might involve the strangulation of the herniated tissue, where the blood supply is cut off, or significant bleeding and ulceration within the esophagus. A large hernia, especially a paraesophageal type, also carries a higher risk of complications like gastric obstruction or ischemia, potentially requiring emergency surgery. The ultimate decision for surgery is made collaboratively with a healthcare professional, taking into account the patient’s overall health and the specific severity of their condition.
Main Surgical Approaches
The repair of a hiatal hernia primarily employs two surgical approaches, each with distinct methodologies. The most common method is laparoscopic repair, a minimally invasive technique. This procedure involves several small incisions, typically less than one centimeter, through which a surgeon inserts a laparoscope—a thin tube equipped with a camera—and specialized instruments. Benefits of this approach include reduced post-operative pain, smaller scars, and a generally quicker recovery period.
In contrast, open repair involves a larger incision in either the abdomen or the chest. This traditional method is less frequently used for hiatal hernias but may be necessary for very large or complex cases, or when previous laparoscopic attempts have not been successful. Regardless of the chosen approach, the overarching goals of the surgery remain consistent: to reposition the stomach, repair the enlarged opening in the diaphragm, and often to reinforce the lower esophageal sphincter. The specific steps involved in achieving these goals are similar across both techniques once access to the surgical site is established.
What Happens During the Procedure
Hiatal hernia repair surgery begins with the administration of general anesthesia. The initial step involves gently returning the portion of the stomach that has bulged through the diaphragm back into its proper position. Following this repositioning, the enlarged opening in the diaphragm, known as the hiatus, is narrowed. This “crural repair” typically involves stitching the diaphragm muscles together to create a tighter seal around the esophagus.
A common and important component of the repair, especially for those experiencing acid reflux, is a fundoplication. This procedure involves wrapping the upper part of the stomach, called the fundus, around the lower end of the esophagus. This wrap creates a new, tighter valve, which helps prevent stomach acid from flowing back into the esophagus.
Two primary types of fundoplication are Nissen fundoplication, a complete 360-degree wrap, and Toupet fundoplication, a partial 270-degree wrap. The choice between these depends on factors like esophageal motility, with Toupet often preferred for patients at higher risk of post-operative swallowing difficulties. In certain situations, particularly for larger hernias, surgical mesh may be used to reinforce the repaired diaphragm opening, though this is not always required.
Post-Operative Recovery and Care
Following hiatal hernia repair, patients can expect a relatively short hospital stay, typically one to two days for laparoscopic procedures, with open surgery potentially requiring a longer period. Pain management is provided to address discomfort in the abdomen and chest, as well as potential shoulder pain from gas used during laparoscopic surgery. A phased dietary progression is common, starting with clear liquids immediately after surgery, advancing to soft or mushy foods for several weeks, and gradually returning to a regular diet over approximately three to six weeks.
Activity restrictions are in place to support healing and prevent strain on the repaired area. Patients are generally advised to avoid heavy lifting, typically nothing over 10-15 pounds, for four to six weeks. Strenuous activities and driving are also restricted initially, with resumption depending on individual comfort and medication use.
Incision care involves keeping the small wounds clean and dry, with dissolvable stitches often used. Follow-up appointments are scheduled to monitor recovery progress and address any concerns. The full recovery timeline can range from a few weeks to several months, varying by individual and surgical technique.
Understanding Potential Complications
While hiatal hernia repair is generally considered a safe procedure, potential complications can arise, as with any surgery. Common surgical risks include infection at the incision sites, bleeding, or adverse reactions to anesthesia. Specific complications related to hiatal hernia repair can also occur.
One common issue is difficulty swallowing, known as dysphagia, which can be temporary due to swelling around the esophagus, especially after fundoplication. This usually resolves within a few weeks to a few months. Another potential concern is gas-bloat syndrome, where patients experience difficulty belching or vomiting due to the tightened valve created by the fundoplication.
Although less common, the hernia can recur, meaning the stomach may again protrude through the diaphragm. Rarely, injury to surrounding organs might occur during the procedure. Patients should discuss these possibilities with their surgeon and report any concerning symptoms during their recovery period.