A hiatal hernia occurs when the upper part of the stomach pushes upward through the opening in the diaphragm, known as the hiatus, and into the chest cavity. This anatomical defect often causes gastroesophageal reflux disease (GERD) symptoms because it compromises the function of the lower esophageal sphincter. Surgical repair, typically involving laparoscopic Nissen fundoplication, aims to pull the stomach back into the abdomen, narrow the diaphragmatic opening, and reinforce the sphincter mechanism. While surgery is effective for severe cases, it is a major procedure requiring general anesthesia and significant recovery, making it unsuitable for every patient. Determining candidacy involves a careful assessment of overall health, the condition of the upper digestive tract, and symptom severity.
Pre-Existing Conditions That Bar Surgery
The most absolute exclusions for hiatal hernia surgery relate to the patient’s ability to safely undergo general anesthesia and withstand the physiological stress of the operation. Any severe, uncontrolled systemic illness significantly raises the risk of life-threatening complications or death during or immediately following the procedure. These conditions make a person medically unfit for elective surgery.
Patients with advanced cardiopulmonary disease, such as recent myocardial infarction, unstable angina, or severe congestive heart failure, face a high risk of perioperative cardiac events. Severe pulmonary conditions, like end-stage Chronic Obstructive Pulmonary Disease (COPD) or pulmonary hypertension, also make managing breathing difficult during and after anesthesia, especially due to changes in abdominal pressure during laparoscopic surgery. Uncorrectable coagulopathies, or severe bleeding disorders, are an absolute contraindication because they prevent proper blood clotting and make controlling surgical bleeding difficult. Uncontrolled kidney or liver failure can severely impair the body’s ability to process anesthesia and recover from surgical trauma.
Anatomical and Functional Esophageal Limitations
Beyond systemic health, certain conditions specific to the esophagus and surrounding anatomy can make hiatal hernia repair technically impossible or likely to fail. The success of a fundoplication relies on creating a functioning valve around the lower esophagus, which requires normal esophageal movement. Severe, irreversible esophageal motility disorders, such as advanced achalasia or aperistalsis (often seen in systemic sclerosis), are a contraindication for a standard Nissen fundoplication. In these instances, the 360-degree wrap would create a complete obstruction, causing severe post-operative difficulty swallowing.
A congenitally or acquired short esophagus presents a significant anatomical challenge, preventing the surgeon from pulling the stomach down into the abdomen for a tension-free repair. Attempting repair without a lengthening procedure can lead to the wrap slipping back into the chest, causing early recurrence and failure. Extensive prior abdominal surgery or radiation therapy in the upper abdomen can also compromise local tissue integrity. Scar tissue and poor tissue quality make it difficult to securely place the sutures needed to close the diaphragmatic hiatus and create the fundoplication, potentially leading to the breakdown of the repair.
When Non-Surgical Management is Prioritized
Some patients are technically fit for surgery, but the procedure is not recommended because the potential benefits do not outweigh the risks, or the likelihood of long-term failure is too high. This often involves a shared decision based on symptom severity and lifestyle factors. For patients with small, asymptomatic hiatal hernias or those with mild symptoms that respond well to medication, surgery is typically deferred. Non-surgical management, including lifestyle changes, weight loss, and medication like proton pump inhibitors (PPIs), must be exhausted before an elective operation is considered.
Two high-risk lifestyle factors often lead to prioritizing non-surgical management or alternative surgical options: severe, uncontrolled obesity and active smoking. Morbid obesity (generally defined as a Body Mass Index (BMI) greater than 35 or 40) is associated with higher rates of surgical failure and recurrence due to persistently elevated intra-abdominal pressure. For these individuals, a combined procedure, such as hiatal hernia repair along with a bariatric operation like a gastric bypass, may be the more effective option to address both the hernia and the underlying pressure. Active smoking impairs wound healing and increases the risk of long-term failure of the diaphragmatic repair, requiring cessation before surgery can be considered.