Hiatal Hernia Surgery
What is a hiatal hernia?
A hiatal hernia occurs when the natural defect in the diaphragm through which the esophagus passes to connect with the stomach is too large. This allows the stomach to herniate into the chest cavity. If the hernia defect is large enough, other organs can move into the chest such as the colon or small intestines.
How is a hiatal hernia repaired?
A hiatal hernia surgery is almost always done laparoscopically with about 5 small incisions. The crura of the diaphragm are the muscular pillars of the diaphram that should be snug around the esophagus. Hiatal hernia repair surgery of a hiatal hernia involves laparoscopically dissecting whatever has herniated into the chest back into the abdomen and closing the crura with suture so that the diaphragm is again snug around the esophagus. It also usually involves a fundoplication which also helps with reflux and to prevent recurrence of the hernia. A hiatal hernia is a structural problem so it can not be repaired with medication though medication may help control symptoms.
How do I know if I have a hiatal hernia and need hiatal hernia repair surgery?
The most common symptom is heartburn but you need a test using X-rays as you swallow contrast and pictures are taken as the contrast passes into the stomach. This test does not require any anesthesia, it is painless (though the contrast may not taste good), and it is done at a hospital. No one can tell if you have a hiatal hernia by simply examining you (which is generally not true of other types of hernias which can be detected on physical exam - Dr. Harris, hiatal hernia surgeon, can also help with these).
Which hiatal hernias need to be fixed?
If you are relatively young and healthy and have a hiatal hernia that is larger than a small sliding type, you should have hiatal hernia repair surgery. If your symptoms are minimal and the hernia is very small, it is reasonable to monitor the hernia with barium swallow studies about every year to make sure the hernia does not become large and therefore more difficult to repair. For patients who are older and have more medical problems, the decision to repair or watch a hiatal hernia is more complicated because the risk of surgery can be higher and the potential benefit may be lower so the decision is very patient specific. Reach out to us if you have questions about hiatal hernia repair surgery.
Dr. Harris' experience with hiatal hernia surgery:
Hiatal hernia is a subset of heartburn and which is a disease entity in which Dr. Harris is particularly well trained. (Most of the following is repeated from our heartburn surgery page). While at the Mayo Clinic, he trained under Dr. C. Dan Smith who is one of the nation’s leaders in reflux and esophageal surgery. In this part of the country, some gastroenterologists can be reluctant to refer patients for anti-reflux surgery even though studies have showed high patient satisfaction with anti-reflux surgery. However, if patients have significant hiatal hernia they are often referred for surgery.
The best study to quantify the size of a hiatal hernia is a barium esophagram or barium swallow. If there is not a significant hiatal hernia and if reflux symptoms are well controlled by medications and the patient does not mind taking these medications, then surgery is often not necessary. However, hiatal hernia repair surgery should be considered in a patient with a significant hiatal hernia even if the patient has minimal symptoms as long as the patient is a reasonable candidate for surgery (healthy enough to tolerate general anesthesia, hiatal hernia laparoscopic surgery, and the small risk of potential complications). Tests that are generally undertaken before anti-reflux surgery include upper endoscopy, barium esophagram, esophageal manometry, esophageal pH testing, and sometimes gastric emptying.
Traditional anti-reflux consists of hiatal hernia repair and a fundoplication. A fundoplication is performed by wrapping the fundus of the stomach (this is the floppy part of the upper stomach) around the end of the esophagus in either a partial or full wrap around the esophagus. There is also a new device called LINX that can be used instead of a fundoplication. Antireflux surgery usually requires a one night stay in the hospital and is almost always done laparoscopically.
Proton pump inhibitor medications are the first line treatment GERD. These work by powerfully reducing the amount of acid the stomach produces. However, they do nothing to stop stomach contents from refluxing into the esophagus where they can still cause symptoms even though they are less acidic. Some studies have suggested that long-term use of proton pump inhibitors may have negative health consequences. The laparoscopic Nissen fundoplication is a well established procedure for the treatment of GERD that has been successfully employed since the early 1990s. It involves wrapping part of the stomach around the end of the esophagus. The side effects are usually temporary trouble swallowing and belching as well as sometimes bloating. The LINX device has been in use for about 1o years and has less side effects than the Nissen. The device consists of a ring of magnetic beads that augment the lower esophageal sphincter. Despite positive study results, most insurance companies have refused to pay for LINX so patients often have to pay for the device themselves or have a Nissen instead.