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Surgery for Hiatal Hernia

Performed laparoscopically when possible

Hiatal hernia is a common condition that does not require invasive treatment in most patients.  Hiatal hernias are often benign and produce few or mild symptoms, or symptoms that can be managed successfully with medications.  However, in some patients they can produce serious symptoms that cannot be managed adequately through drug therapy. 

In the more common type of hiatal hernia, the connecting portion of stomach and esophagus push up through an opening in the chest diaphragm; whereas, in a paraesophageal hiatal hernia, a pocket of the stomach separate from this connecting portion pushes up through the diaphragm on its own.  Hiatal hernias, especially paraesophageal hernias, can create complications that may need emergent or urgent surgical intervention.  Or, they may bring the potential for complications that should be corrected without significant delay.  (Candidates for surgery also include younger patients with severe manifestations of reflux disease who want or need to avoid lifelong drug therapy, or patients who have respiratory conditions and cannot risk aspiration pneumonia.)

In a high percentage of patients with paraesophageal hernia, the protruding, herniated portion of the stomach becomes strangulated (squeezed so tightly that its circulation is cut off) or even sometimes causes a twisting of the intestine below the compromised stomach area.  This can result in tearing or puncture of the digestive tract that is often fatal.  For these reasons, physicians will usually recommend that such patients undergo repair of the condition to prevent complications in the future.

Surgery for hiatal hernia involves gently pushing the stomach or other organs back into place through the diaphragmatic opening (hiatus) and repairing this opening to close and tighten it and prevent future herniation.  The surgeon stitches the hiatus to create a snug entry at the gastroesophageal juncture. The team may use special surgical mesh to help reinforce larger areas when it closes the diaphragm.  To prevent the stomach from migrating upwards during healing, the surgeon may also suture the stomach to connective tissue in the abdomen, or place into the stomach a feeding tube that exits through the skin of the abdomen.

Surgeons have traditionally performed this surgery using a conventional open incision into the chest wall or abdomen but today are increasingly offering the operation as a laparoscopic procedure that lessens the invasiveness of the surgery.   In this latter type of surgery, the surgeon makes several very small incisions in the abdomen, through which the team inserts the scope and laparoscopic instruments.  This minimally invasive approach results in less scarring and pain, faster healing, and quicker recover.

Surgery for hiatal hernias serves to reinforce the position and function of the esophageal sphincter, thus helping to address symptoms of reflux.  In the same operation, the surgical team will sometimes also combine the fundoplication procedure used to treat severe reflux, for patients who may need an additional step in addressing a reflux condition.  In this procedure, the surgeon wraps the upper portion of the stomach around the stomach-esophageal connection to tighten the separation between the two areas.

Patients who undergo laparoscopic surgery will spend at least one night in the hospital, and patients who undergo open surgery will need to stay several nights in the hospital.  Most patients are mobile the day after their surgery, are able to resume activities within a week, and are able to make a complete recovery within two to three weeks (twice this for open surgery).  Strenuous exertion, though must be avoided for several months.

Hiatal hernia surgery, which closes and repairs the defect in the patient’s diaphragm, is safe and effective.  It provides successful treatment for reflux symptoms in the vast majority of patients.  Specialists in Aria's Division of Gastrointestinal Disease are experts in helping to diagnose hiatal hernias.