Hiatal Hernia Surgery: Overview

Hiatal hernia surgery (also known as “hiatal hernia repair”) is a procedure that treats hiatal hernia, a condition in which the stomach pushes into the chest cavity. This occurs due to weakness in the diaphragm, a thin band of muscle that keeps the abdomen and chest cavity separate.

While this type of hernia is usually asymptomatic, it’s a common cause of chronic gastroesophageal reflux disease (GERD) and can lead to other issues. The surgery takes on a range of symptoms, including heartburn and acid regurgitation, pain in the chest, difficulty swallowing, shortness of breath, dry cough, nausea, vomiting, bad breath, and fainting, among others.

If less-invasive treatments don’t alleviate these issues, hiatal hernia surgery will be considered to physically repair the diaphragm and reposition the stomach and esophagus.

This procedure is performed using minimally-invasive techniques that require smaller incisions, so not only is it successful in alleviating symptoms, recovery is well-tolerated and relatively quick. If you’re considering this surgery, it’s essential to understand as much as you can about it.

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What Is Hiatal Hernia Surgery?

The primary aim of hiatal hernia surgery is to restore proper anatomy of the stomach and esophagus. During surgery, doctors locate the tear in the diaphragm and use various techniques to repair and reinforce the area, after moving the stomach back into place.

Though open surgery may be required in the most severe cases, hiatal hernia is usually repaired using laparoscopic or endoscopic techniques, which require smaller incisions. The latter two rely on using specialized surgical tools as well as laparoscopes and endoscopes, which are cameras that can access the problem area and provide real-time video imagery for the surgeon.

Approaches have come a long way with this treatment, and nowadays some hiatal hernia surgeries are performed using robotic assistance.

Various Surgery Techniques

There are several types of hiatal hernia surgery, and the choice of procedure depends on the severity and specific location of the hernia. How do these work? Here’s a quick breakdown:

  • Hiatus repair: Early-stage hiatal hernia can be taken on by reducing the size of the hiatus, which is the opening in the diaphragm that allows the esophagus to pass through on its way to the stomach. This is done by using sutures and a special surgical mesh to reinforce the damaged area after the organs are put into proper position.
  • Nissen fundoplication: For cases of “sliding hiatal hernia”—the most common form, in which the stomach slides in and out of the chest cavity—this procedure involves wrapping the “fundus” or upper portion of the stomach around the bottom portion of the esophagus. This creates a bulge of tissue that keeps the stomach in its proper place. This procedure also involves reinforces the diaphragm walls around the esophagus.
  • Collis-Nissen gastroplasty: Cases of paraesophageal hernia, a potentially more dangerous form in which the stomach pushes through the hiatus to emerge next to the esophagus, are treated with Collis-Nissen gastroplasty. In this endoscopic procedure, the surgeon uses the upper portion of the stomach to lengthen the esophagus using a special, flexible tube and reinforcing anatomy using surgical staples, mesh, and Nissen fundoplication.

Contraindications

By nature of being minimally-invasive, hiatal hernia surgery is tolerable and acceptable for most people. Except in special circumstances, doctors will first try other methods—such as lifestyle changes and medications—before calling for this operation.

There are, however, some who may not be good candidates and for whom this treatment is contraindicated, including:

  • Asymptomatic patients: Those who aren’t displaying any symptoms should not undergo surgery. In cases of sliding hiatus hernia that are only mildly symptomatic, doctors will try to consider other options first.
  • History of heart problems: Patients who have a history of heart attack or other heart health issues may have trouble with general anesthesia, making hiatal hernia surgery potentially very dangerous.
  • Lung issues: As above, those with severe or chronic respiratory problems—such as lung cancer or chronic pulmonary obstructive disease (COPD)—might also not do well with the general anesthesia associated with this surgery.
  • Prior abdominal surgery: A history of surgery in the abdominal region may also make aspects of this treatment challenging and even risky to undertake. As such, those with extensive prior surgical history may be poor candidates.

Notably, hiatal hernia surgery is considered safe for patients of all ages, though extra considerations are taken with pediatric and older populations. Of course, a standard aspect of this care will be thorough clinical evaluation and screening to ensure safety and success.

Potential Risks

While hiatal hernia surgery is safe and has a high success rate—recurrence of the problem is expected to occur in only 5 to 10% of cases—there is always a significant chance of complications . In the case of this treatment, most of these are more easily managed and don’t require additional surgery. The risks of undergoing this surgery include:

  • Intraoperative bleeding: Always a risk during surgery, in this treatment, the spleen can be punctured, leading to uncontrolled bleeding.
  • Thoracic injury: Depending on the location and type of hernia, surgical screws may be used in surgery; in the very rare cases where these are not positioned correctly, they can damage parts of the thorax in the throat.
  • Abdominal organ damage: In some cases, surrounding organs can become damaged as the surgical team tries to reposition the stomach and repair the issue. Sometimes, too, the spleen can become damaged due to Nissen fundoplication as the upper part of the stomach is wrapped around the esophagus.
  • Collapsed lung (pneumothorax): Sometimes, the lung is accidentally punctured during surgery. When air leaks from it, the change in pressure will cause it to collapse, a condition referred to clinically as collapsed lung or “pneumothorax.” This is usually caught while work is ongoing, and damage can be sutured shut.
  • Recurrence: While, overall, most hiatal hernia surgeries succeed in permanently repairing the damage, there is always a chance of the hernia returning. If symptoms of this recurrence are disruptive, then re-operation is considered.

Purpose of Hiatal Hernia Surgery

There are two kinds of hernia taken on with this surgery: sliding hiatal hernia and paraesophageal hernia. The former of these refers to cases where the stomach is able to slide in and out of position, whereas the latter, more severe type, it's moved permanently into the chest cavity. What diagnoses prompt consideration of this procedure? Here's a quick breakdown:

  • Gastroesophageal reflux disease (GERD) is the most common reason surgery will be attempted. Caused by stomach acids flushing the esophagus, this chronic and severe heartburn leads to vomiting, nausea, and chest pains, among other symptoms.
  • Paraesophageal hernia, being more severe than hiatal hernia, may lead to cases where the stomach or esophagus’s blood supply is impacted. Not only can this lead to dangerous undernourishment of these organs, other symptoms include difficulty swallowing, fatigue, and fainting. This type tends to be larger in size, and more often warrants surgery.

It's important to note that surgery is rarely a first-line treatment, it is only considered after non-invasive treatments have been attempted. Doctors will try nutrition counseling, as well as stomach acid managing medications first.

A number of tests are done for diagnosing these conditions:

  • Upper endoscopy involves the use of a special tube with a camera (an endoscope) that runs down your throat to let the doctor evaluate the area.
  • Esophageal manometry is a test to check the muscle function of the esophagus as you swallow. This involves passing a tube outfitted with sensors through the nose to the esophagus.
  • pH test evaluates the relative acidity of your throat and can determine if this is related to stomach acids flooding the esophagus.
  • Upper gastric (UGI) series, sometimes known as a "barium swallow," is a diagnostic technique in which patients ingest a radioactive compound to allow doctors better resolution using X-ray imaging. It can tell doctors the size and scope of the hernia.

How to Prepare

While hiatal hernia surgery is a minimally-invasive procedure, and you'll often need to recover in the hospital for two nights. Preparation for this surgery means understanding what will occur, where treatment takes place, what you need to have with you, and what to expect.

Location

Following consultation with an anesthesiologist and a final evaluation in the pre-operative room, you'll be taken to the operating room. Among the equipment you'll find there are:

  • The operating table on which you'll be placed and put to sleep.
  • Lights to make sure surgeons can see their work.
  • Video monitors help the guide the surgeons.
  • Laparoscope is an adjustable tube with a camera.
  • Endoscope allows a camera running down the throat to access the area.
  • Ventilator to assist with breathing while you're under anesthesia.
  • Monitors that track your vital signs.
  • Robotic assistance may be used and is a more recent technique that employs robotic hands guided by the surgeon.

What to Wear

As your doctor will tell you, plan on wearing the same, comfortable clothes home, as you did to the hospital. What should you keep in mind in terms of wardrobe? Here are some quick tips:

  • Loose-fitting clothes should be worn to protect your incisions.
  • Wearing a hospital gown will be necessary for surgery.
  • Leave extra clothes at home as you will not need to change during your hospital stay.
  • No jewelry, watches, or valuables are necessary.
  • Go scent-free and skip perfumes or colognes.
  • Robe and slippers are good to have along for comfort in the hospital.

Food and Drink

Dietary guidelines are often needed in hiatal hernia cases, and patients will also need to keep some pre-operative dietary guidelines in mind. Most notably, you should not eat or drink anything for at least eight hours prior to your procedure.

On top of that, your doctor may be put you on a low-sugar, liquid-based pre-operative diet for two to 10 days before surgery. They'll tell you more about it, but this typically entails featuring:

  • Juices, such as orange juice, grapefruit, or others
  • Milk at a minimum of one cup a day, or 8 ounces of yogurt
  • Protein shakes
  • Jello or soft-gelatin foods
  • Broth from chicken, beef, or seafood

Medications

Before hiatal hernia surgery, you typically won't be on any specific medications, though the doctor may give you something to help with heartburn. Notably, some drugs and vitamin supplements should be avoided before surgery because they can affect the blood's ability to clot:

  • Coumadin (Warfarin)
  • Plavix (clopidogrel)
  • Excedrin, Anacin (aspirin)
  • Advil, Motrin (ibuprofen)
  • Aleve, Naprosyn (naproxen)
  • Vitamin E

It's absolutely essential that you let your doctor know exactly what prescribed and over-the-counter drugs you're taking, as well as any other vitamins or herbal supplements you're taking.

What to Bring

Make sure to have:

  • List of medications
  • Photo ID
  • Insurance card or information
  • Advance healthcare directive
  • Face-wash, chapstick, toothpaste, toothbrush
  • CPAP machine
  • Incentive spirometer

Pre-Op Lifestyle Changes

Prior to surgery, your doctor may also recommend several important lifestyle changes:

What to Expect on the Day of Surgery

From start to finish, hiatal hernia surgery typically takes three to four hours. However, on the day of surgery, there's much more that happens: doctors have to ensure your ready for the procedure, perform it, and then ensure that early recovery is going smoothly.

Before the Surgery

Performed in the pre-op room, you'll first undergo an initial evaluation. Here's a quick breakdown:

  • Testing of heart rate, breathing, and other important measures to ensure your body is ready for treatment.
  • Medications to prevent blood clots and reduce the chance of infections will be delivered.
  • Anesthesia, which puts you to sleep, is necessary, so you'll also consult with the anesthesiologist to determine the best dosage.

During the Surgery

A couple of different techniques may be used to perform this surgery. In severe cases, an open surgery may be employed—this requires larger incisions—but in most cases, laparoscopic Nissen fundoplication is used. There may be variations, but here's a rundown of how it works:

  • Anesthesia: This is delivered to you once you get into the operating theater and will put you to sleep.
  • Inserting laparoscope: Surgeons make small incisions and pass through the laparoscope, to let them see the affected area.
  • Carbon gas: To help make the area more operable, carbon gas will be delivered to the stomach and esophagus.
  • Accessing the hernia: Via four other small incisions made in the abdomen, the surgeon will be able to guide surgical tools to the hernia.
  • Wrapping the stomach: The upper portion of the stomach is wrapped around the esophagus to reinforce the area, using a special tube called a "bougie."
  • Hernia repair: As necessary, and with the stomach in position, the doctor may reinforce the weakened walls of the esophagus with a mesh or stitches.
  • Closure: Lastly, the surgeon removes all of the equipment and closes up the sutures.

After the Surgery

In the post-operative recovery period—which entails at least one night in the hospital—the medical staff will be monitoring your progress carefully and keeping an eye out for complications. What does in-hospital recovery look like? Here's what happens:

  • Post-operative recovery: After the procedure, you'll wake up in the recovery room, still connected to machines as well as a catheter for urination, and, in some cases, a nasogastric tube running through your nose to your stomach. Your vital signs will be monitored, and once you're alert and these are stable, you'll be moved to the hospital room.
  • In the hospital room: The doctors will give you medications to help manage your pain as you recover, and you'll be encouraged to get up and walk a little to prevent blood clots.
  • Breathing exercises: Strengthening the lungs is a priority after surgery, and you'll have to regularly use a device called an incentive spirometer to give them exercise.
  • Liquid diet: For about three weeks following surgery, you'll be on an all-liquid diet, which starts in the hospital. In the hospital, you'll consult with the doctor or a dietician explaining what you can and cannot consume.

Prior to discharge, doctors want to ensure that there are no complications with the surgery, that you are in stable conditions, and are able to digest foods.

Recovery

Complete recovery from hiatal hernia surgery takes three to four weeks, and this period is absolutely essential for a positive outcome. Physical therapy isn't needed. Many lifestyle adjustments may need to be made in this time, and you'll need to be open and communicative with your doctor. In addition, you'll have to come back in for a follow-up appointment at two weeks.

Recovery Timeline

Keep this in mind for how recovery may progress:

  • Return to work: While some may be able to return earlier, it's recommended that you take at least one to two weeks off following surgery.
  • Activity: There actually aren't restrictions on activity following this surgery, and remaining active helps promote recovery. However, avoid lifting heavy objects for at least three weeks.
  • Driving: You may be prescribed opioid drugs to manage pain, which can affect your ability to drive. Don't start driving until it's been at least two days since your last dose.

Healing

Successful recovery from hiatal hernia requires careful attention to how your feeling, as well as a number of other important factors. You'll feel some tightness in your throat due to swelling following surgery and fatigue for one to two weeks following surgery. Furthermore, patients may develop constipation or diarrhea during the first week following the procedure.

Care for the incisions is particularly important; here's what you should keep in mind:

  • Sutures: If your doctor used sutures, stitches, or surgical to close the incisions, you're free to take off the bandages and take a shower one day after surgery. These either need to be taken out by the doctor or will fall off on their own; don't try to remove them yourself.
  • Steristrips: Instead of stitches, some doctors use a special tape to close the wounds. Keep them dry. If you want to shower, tape plastic over the affected areas. Let these flake off on their own.
  • No soaking: Until you get your doctor's OK, you should not go swimming or take baths.

Since hiatal hernia surgery treats the stomach and esophagus, you'll need to be on a very restrictive, liquid-based diet during recovery. Your doctor will tell you more about it, but here are the basics:

  • Clear liquids: Until your doctor gives you the OK—usually for the first two weeks—you'll be on an all-liquid diet. This means that protein shakes and broths will be your main form of protein, and you won't be able to tolerate any solid foods.
  • Portion control: When on the all-liquid diet, you'll have to be careful about drinking too much at once. Start off by sipping one cup at a time.
  • Soft foods: After two weeks, you'll be allowed to gradually introduce soft solid foods to your diet. These need to be cooked.
  • Carbonated beverages: You'll need to avoid all carbonated or sparkling drinks for at least three weeks.
  • Alcohol: Abstain from drinking while you're on your pain medications.
  • Straws: Since these can cause air to go into your stomach, don't use straws during recovery.
  • Multivitamins: Listen carefully to your doctor about any supplements you need to take, as well as any other dietary specifications.

Once you have clearance from your doctor, usually after three weeks, you'll be able to resume a more normal diet.

Coping With Recovery

The most immediate concern following hiatal hernia surgery is pain, and you will be prescribed strong opioid medications to manage it. Be very careful about using these and follow the prescription exactly, and keep in mind that these can significantly affect motor function.

Over time, you'll need to taper off of these drugs and can begin using over-the-counter non-steroidal anti-inflammatory drugs (NSAID) like ibuprofen or others. If you have any pills left over, dispose of them properly by taking the unused portion to the pharmacist.

Long-Term Care

In most cases, hiatal hernia surgery will effectively correct GERD or other gastrointestinal symptoms, reducing the need for medications. But ensuring symptoms come back should also be a life-long project, and it may take some significant lifestyle changes. Here's what may be recommended:

  • Lose weight if overweight or obese
  • Reduce typical portion size during meals
  • Avoid acidic foods like tomatoes, citrus, and others
  • Limit fried foods
  • Cut out coffee or caffeinated foods or beverages
  • Quit smoking
  • Take meals at least three hours before lying down
  • Keep your head raised 6 inches above your body when lying down

A Word From Verywell

Even though it’s routine and well-tolerated by patients, there’s no doubt that the prospect of undergoing hiatal hernia surgery can be intimidating. Uncertainty and anxiety are not uncommon in those considering treatments of this scale.

However, it’s important to remember that not only does this operation significantly reduce symptoms, but the way it’s performed today makes it safer and more effective than ever before. With a dedicated surgeon and hospital staff— alongside your family and support-network—the pain and discomfort associated with hiatal hernia will surely become a thing of the past.    

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Article Sources
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