A hiatal hernia occurs when the upper part of the stomach pushes up through the hiatus, a natural opening in the diaphragm, into the chest cavity. The diaphragm is the muscular sheet separating the chest and abdomen. When this opening widens, a portion of the stomach can protrude, often leading to symptoms like heartburn and acid reflux. Treatment ranges from simple lifestyle adjustments to surgical correction for cases that do not respond to medical management.
Initial Management and Non-Surgical Treatment
Management typically begins with a primary care physician or a gastroenterologist, a specialist in digestive health. These practitioners focus on alleviating the symptoms of gastroesophageal reflux disease (GERD) that often accompany the hernia, rather than physically repairing the defect. Initial treatment centers on lifestyle modifications designed to reduce pressure on the abdomen and limit acid production.
Modifications include avoiding trigger foods, losing weight to decrease intra-abdominal pressure, and elevating the head of the bed during sleep to prevent nighttime reflux. Pharmaceutical interventions are also employed, primarily using medications that neutralize or suppress stomach acid. Over-the-counter antacids provide immediate, short-term relief by buffering stomach acid.
If symptoms persist, stronger prescription medications are used, such as histamine H2 receptor blockers or proton pump inhibitors (PPIs). PPIs work by directly blocking the acid pumps in the stomach lining, offering more potent and sustained acid suppression. For the majority of patients with a common sliding hiatal hernia (Type I), this medical and lifestyle management is sufficient to control symptoms.
Criteria for Surgical Intervention
The decision to transition to surgical intervention is based on the severity of symptoms and the specific type of hernia involved. Surgery is considered when a patient has intractable reflux, meaning symptoms persist despite maximum medical therapy with PPIs. Chronic, severe reflux can lead to complications such as esophageal strictures, bleeding, or changes in the esophageal lining like Barrett’s esophagus.
The type of hernia is a major determinant of surgical necessity, especially with the less common paraesophageal hernias (Types II, III, and IV). These hernias are more serious because they involve the stomach or other organs moving alongside the esophagus, increasing the risk of mechanical complications. Paraesophageal hernias are frequently recommended for repair, even if symptoms are mild, due to the possibility of gastric volvulus (stomach twisting) or strangulation, which are life-threatening emergencies. Surgical repair is also indicated for large sliding hernias, often defined as those greater than seven centimeters or involving more than 50% of the stomach.
The Surgical Specialists
Hiatal hernia repair is performed by distinct surgical specialists trained to handle the complexity of the upper gastrointestinal tract. The procedure is most commonly performed by a General Surgeon, especially those with fellowship training in minimally invasive or foregut surgery. These surgeons specialize in the digestive system and are experienced in laparoscopic techniques, which is the standard approach for most repairs.
Thoracic Surgeons, who specialize in organs within the chest cavity, also perform hiatal hernia repair, particularly for large or complex paraesophageal hernias requiring a transthoracic approach. Outcomes are generally comparable between general and thoracic surgeons, as factors like the surgical approach and patient health often have a greater influence than the surgeon’s primary specialty. The highest level of expertise is typically found in surgeons dedicated to benign foregut disease. These specialists possess a comprehensive understanding of esophageal physiology and perform a high volume of these operations, leading to improved long-term outcomes.
Understanding the Repair Procedures
Surgical repair, known as a hiatal hernia repair with fundoplication, has two main objectives: returning the stomach to the abdomen and creating an anti-reflux barrier. The procedure is performed using minimally invasive techniques, such as laparoscopy or robotic-assisted surgery, which involve several small incisions. This approach typically leads to shorter hospital stays and faster recovery compared to traditional open surgery.
The first step is the reduction of the herniated stomach back into the abdominal cavity. The surgeon then closes the widened diaphragmatic opening, or hiatus, by stitching the muscle pillars (crura) together, a step called cruroplasty. For larger defects, surgical mesh may be used to reinforce the closure and reduce the risk of recurrence.
The second component involves a fundoplication, which creates a new valve mechanism to prevent reflux. The upper part of the stomach, called the fundus, is wrapped around the lower esophagus to reinforce the lower esophageal sphincter. The two most common types are the Nissen fundoplication (a complete 360-degree wrap) and the Toupet fundoplication (a partial 270-degree posterior wrap). The Nissen procedure offers robust reflux control but carries a higher risk of postoperative dysphagia. The Toupet procedure is often preferred for patients with poor esophageal motility, as the partial wrap is less restrictive.