What is Hiatal Hernia Repair?
A hiatal hernia repair is a surgical procedure performed for the treatment of a medical condition called hiatal hernia.
A hernia is a bulge that develops when the internal organs of the abdominal cavity are pushed out through a weakened spot in the abdominal wall. Hiatal hernia is a condition in which part of the stomach slides through the hiatus, an opening in the diaphragm, and protrudes into the chest.
It is not exactly clear what causes a hiatal hernia. Some of the possible causes may include weakening of the supporting tissues due to an injury or increased pressure in the abdomen from coughing, lifting heavy objects, or straining during a bowel movement. The condition may also occur due to a congenital defect where the hiatus is unusually large.
During a hiatal hernia repair, your surgeon pulls the section of the stomach that has protruded into the chest back into the abdomen and makes the diaphragm opening smaller to prevent recurrence of hiatal hernia.
The diaphragm is the muscular sheet that separates the lungs and chest from the abdomen and helps in breathing. The esophagus (food pipe) passes through the diaphragm at the hiatus and opens into the stomach, which is present below the diaphragm.
Indications of Hiatal Hernia Repair
A small hiatal hernia may not cause any problem, but a more severe one causes gastroesophageal reflux disease (GERD), characterized by heartburn, acid reflux, nausea, chest or abdominal pain, bloating, belching, and difficulty swallowing. These symptoms may be treated with lifestyle changes and medications. However, your physician may recommend hiatal hernia repair if:
- The symptoms become severe and significantly interrupt your quality of life
- The symptoms do not respond to conservative treatment
- The hiatal hernia is at risk of getting entrapped and strangulated, thereby cutting off the blood supply to the trapped part, leading to necrosis (death of the trapped tissue)
- Symptoms worsen to blood in the stools, blood in the vomitus, ulcers, difficulty breathing, difficulty passing stools or gas, or narrowing of the esophagus
Preparation for Hiatal Hernia Repair
In general, preoperative preparation for hiatal hernia repair will involve the following steps:
- A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to the surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications, vitamins, or supplements that you are taking.
- You may need to refrain from medications such as blood thinners or anti-inflammatories for 1 to 2 weeks prior to surgery.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should shower with an antibacterial soap the night or morning prior to the operation.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery has been explained.
Procedure for Hiatal Hernia Repair
Hiatal hernia repair can be performed as an open or keyhole (laparoscopic) surgery, where the bulge is pushed back into place, the hiatus is tightened, and the stomach is secured into place with sutures. The open surgery is only recommended in certain, severe instances of hiatal hernia, and the great majority of procedures are usually performed laparoscopically (Nissen fundoplication). Both types of surgeries are usually performed under the influence of general anesthesia.
Open Hiatal Hernia Repair
During an open hiatal hernia repair, your surgeon makes a large surgical cut on the abdomen. Your surgeon then pulls the protruded part of the stomach back into the abdominal cavity and wraps the upper part of the stomach, called the fundus, around the lower portion of the esophagus. This helps to create a tighter sphincter which prevents the stomach acid from leaking up into the esophagus (acid reflux). In some cases, your surgeon may temporarily place a tube to hold the stomach in position, and this tube will be removed after several weeks at a follow-up visit.
Laparoscopic Hiatal Hernia Repair
A Nissen fundoplication is the most commonly performed laparoscopic surgery for a hiatal hernia repair.
Your surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which a laparoscope (a small thin tube with a light source and tiny video camera connected to a television monitor) is introduced into the abdomen. A harmless gas is injected into the abdominal cavity near the belly button to expand the viewing area of the abdomen, providing a clear view to your surgeon and sufficient room to work. Additional small incisions may be made to insert other surgical instruments. The video camera attached to the laparoscope will send magnified images to a monitor, which will guide your surgeon throughout the surgery.
During the procedure, your surgeon first repairs the hiatal hernia, by bringing your stomach down into your abdominal cavity. Sometimes, a type of mesh may be inserted to support and strengthen it. Your surgeon then wraps the upper part of the stomach, the fundus, around the lower esophagus to create a valve, suturing it in place. This surgery strengthens the muscles and helps prevent stomach acid and food from flowing back into the esophagus. The laparoscope and other instruments are removed, and the gas released. The tiny incisions are closed and covered with small bandages.
Advantages of a laparoscopic procedure over the open surgical method include shorter hospital stays, smaller incisions, less post-operative pain, and a faster recovery.
Postoperative Care Instructions and Recovery
In general, postoperative care instructions and recovery after hiatal hernia repair will involve the following steps:
- You will be transferred to the recovery area where your nurse will monitor your vital signs as you recover from the effects of anesthesia.
- Most patients are able to go home the same day or the next day if it is a laparoscopic procedure or after two to three days if it is an open surgery.
- You may notice some pain, swelling, and discomfort in the abdominal area. Pain and anti-inflammatory medications are provided as needed.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You are encouraged to walk with assistance as frequently as possible to prevent the risk of blood clots.
- If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple of days while the excess gas is being absorbed.
- Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
- Diet instructions include having several small meals throughout the day and avoiding or limiting foods that contribute to bloating, gas, and acid reflux symptoms.
- Refrain from strenuous activities, lifting heavy weights, and driving at least for the first few weeks. A gradual increase in activities over a period of time is recommended.
- Typically, you will be able to return to work and resume your daily activities in a week or two after surgery.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications of Hiatal Hernia Repair
Hiatal hernia repair surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Infection at the incision site or mesh
- Postoperative pain and fever
- Blood or fluid accumulation
- Anesthetic reactions
- Recurrence of hernia
- Blood clots
- Scar tissue formation
- Swallowing difficulties
- Injury to surrounding soft-tissue structures or organs