Hiatal hernia repair

Definition

Hiatal hernia repair is surgery to correct a defect in the diaphragm, the breathing muscle that separates the chest area from the stomach area.

Alternative Names

Fundoplication; Anti-reflux surgery

Description

A hiatal hernia occurs when the normal opening in the diaphragm is too large. If the problem is not repaired, the stomach or other abdominal contents may bulge (herniate) into the chest, causing heartburn (acid reflux) and serious damage to the esophagus.

In some cases, a hiatal hernia can cause twisting of the intestines or stomach. This condition is called a voluvlus. It is a life-threatening emergency that requires immediate treatment.

For an open hiatal hernia repair, a cut is made in the stomach area (abdomen) while the patient is under general anesthesia (asleep, no pain). The surgeon tightens the hiatus. The upper part of the stomach (fundus) may be wrapped around the esophagus (fundoplication) to reduce heartburn due to acid reflux. Sometimes the surgeon will place a temporary tube from the stomach through the abdominal wall to keep the stomach in place.

In some patients, this operation can also be done with a laparoscope -- a method called "keyhole" or "telescopic" surgery. A laparoscope is a thin, hollow tube with a mini-camera on the end. Surgical tools can be sent through the laparoscope. Laparoscopic procedures use smaller cuts than open surgery, which results in less pain and scarring and shorter hospital stays.

A new procedure called endoluminal fundoplication uses a special scope (endoscope) to place small clips on the inside of the esophagus. The procedure is done to help prevent reflux.

Indications

Hiatal hernia repair may be recommended when the patient has some of these symptoms:

• Severe heartburn
• Severe inflammation of the esophagus due to the backflow of gastric fluids (reflux)
• Narrowing of the esophagus due to acid damage (esophageal stricture)
• Chronic inflammation of the lungs (pneumonia) due to frequent breathing in (aspiration) of gastric fluids
• A hiatal hernia that raises the risk of the stomach getting stuck in the chest or twisting on itself (para-esophageal hernia)

Risks

Risks specific to this surgery include:

• Gas bloat, which causes difficulty burping or vomiting and results in bloating after meals. This occurs in about 40% of cases but gradually improves in most patients. In rare cases, the bloating is long term.
• Pain with swallowing (dysphagia) occurs in 5 - 40% of patients, but improves over the first 3 months in almost all patients.
• Damage to the stomach or esophagus (rare)
• Recurrence of the hiatal hernia

Risks for any anesthesia include the following:

• Reactions to medications
• Breathing problems, pneumonia
• Heart problems

Risks for any surgery include the following:

• Bleeding
• Infection

Expectations after surgery

Hiatal hernia repair is a safe, effective operation. Reflux is greatly reduced or eliminated in 95% of patients.

Convalescence

Patients who have laparoscopic surgery typically spend 1 to 3 days in hospital. Those who have open surgery may spent 2 to 6 days in the hospital after the procedure.

During surgery, a tube was placed into the stomach through the nose and throat (nasogastric tube). Some surgeons like to leave the tube in for a few days after the procedure, while others do not.

Eat small, frequent meals after the surgery and avoid gas-producing foods.

Most patients go back to work in 2-3 weeks for laparoscopic surgery, or 4-6 weeks after open surgery.