A hiatal hernia occurs when the upper part of the stomach pushes up through the hiatus, an opening in the diaphragm, into the chest cavity. This can cause the lower esophageal sphincter, the muscle that prevents stomach contents from flowing back up, to malfunction. Hiatal hernia surgery returns the stomach to its correct position in the abdomen and repairs the enlarged opening in the diaphragm. The goal is to restore the barrier function between the stomach and the esophagus to alleviate chronic symptoms.
Necessity and Indications for Surgery
Surgery is typically reserved for individuals whose symptoms are severe and unresponsive to conservative medical management. Treatment often involves lifestyle changes and medications like proton pump inhibitors (PPIs). When severe heartburn, chronic regurgitation, or chest pain persist despite drug therapy, elective surgery may be recommended. Elective repair is also considered for patients with large hernias that cause non-reflux symptoms such as difficulty swallowing, early satiety, or anemia from chronic bleeding.
Urgent surgery is indicated for complications, particularly with paraesophageal hernias. These hernias carry a higher risk of acute complications like incarceration (where the stomach becomes trapped) or strangulation (where the blood supply is cut off). Symptoms such as sudden, severe chest or abdominal pain, inability to vomit, and respiratory distress are medical emergencies that require immediate surgical intervention. This prevents tissue death and potential perforation, which carries a high mortality rate.
Detailed Steps of the Surgical Repair
Most hiatal hernia repairs are performed using a minimally invasive laparoscopic approach. This technique offers advantages over open surgery, including reduced pain, less scarring, and a shorter hospital stay. The procedure begins with the surgeon dissecting the hernia sac and mobilizing the stomach and lower esophagus to pull them back down into the abdominal cavity. Achieving a sufficient length of esophagus that lies below the diaphragm, typically a minimum of two to three centimeters, ensures long-term repair stability.
The crural repair focuses on tightening the enlarged hiatus in the diaphragm. The surgeon uses sutures to re-approximate the muscle pillars (crura) of the diaphragm behind the esophagus. For larger defects, a surgical mesh may be used to reinforce the weakened tissue and prevent the hernia from recurring. This anatomical restoration corrects the herniation itself, but it is often insufficient to fully resolve chronic acid reflux.
The repair is commonly combined with an anti-reflux procedure, usually a Nissen fundoplication. This technique reinforces the lower esophageal sphincter by wrapping the upper part of the stomach (the fundus) around the lower esophagus. The fundus is wrapped a full 360 degrees and secured with sutures to create a new valve mechanism. This reconstructed barrier exerts pressure on the lower esophagus, preventing the reflux of stomach acid.
Post-Operative Recovery and Long-Term Outlook
Following a laparoscopic repair, patients typically have a short hospital stay, usually one to two days. Recovery focuses on protecting the fundoplication wrap. A structured dietary progression is necessary, starting with clear liquids immediately after surgery, advancing to a full liquid and then soft-food diet for several weeks. This carefully managed diet allows the swelling around the esophagus to subside and prevents undue strain on the wrap.
Patients must avoid activities that increase intra-abdominal pressure, such as heavy lifting, straining, or vigorous exercise, for about six to eight weeks. Returning to light activity is often possible within two weeks, but a full recovery can take up to three months. The long-term outlook for hiatal hernia repair with fundoplication is favorable, with success rates of 90% or higher reported in relieving severe GERD symptoms.
Some patients may experience new symptoms related to the fundoplication. Common side effects include temporary difficulty swallowing (dysphagia) due to post-operative swelling or a wrap that is too tight. Another potential issue is gas bloat syndrome, where patients have difficulty belching or vomiting because the tight wrap prevents the release of gas from the stomach. These side effects are often manageable, but persistent or severe symptoms may require further evaluation.