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; Nissen; 360-degree wrap
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 volvulus. 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 you are 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 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. This 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.
Why the Procedure is Performed
Hiatal hernia repair may be recommended if you have:
- Severe heartburn that does not get better with medication
- Less severe heartburn that does not get better with medication (in younger patients)
- 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)
- Damage to the esophagus from reflux, as an alternative to taking medication for your entire life
Risks
Risks with this surgery include:
- Damage to the stomach, esophagus, spleen, or liver (rare)
- Gas bloat, which causes difficulty burping or vomiting and leads to bloating after meals. This occurs in about 40% of patients, but gradually improves in most patients. In rare cases, the bloating is long-term.
- Pain with swallowing (dysphagia) may occur, but improves over the first 3 months in almost all patients.
- Pneumothorax
- Return of the hiatal hernia
Risks for any anesthesia include the following:
- Breathing problems, pneumonia
- Heart problems
- Reactions to medications
Risks for any surgery include the following:
- Bleeding
- Infection
Outlook (Prognosis)
Hiatal hernia repair is a safe, effective operation. Reflux is greatly reduced or eliminated in most patients.
Recovery
Patients who have laparoscopic surgery typically spend 1 - 3 days in the hospital. Those who have open surgery may spend 2 - 6 days in the hospital after the procedure.
During surgery, a tube is 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 2 - 3 weeks after laparoscopic surgery, or 4 - 6 weeks after open surgery.
References
Wang KK, Samplinger RE. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett's esophagus. Am J Gastroenterol. 2008;103:788-797.
Wilson JF. In the clinic. Gastroesophageal reflux disease. Ann Intern Med. 2008;149(3):ITC2-1-15; quiz ITC2-16.
Oelschlager BK, Eubanks TR, Pellegrini CA. Hiatal Hernia and Gastroesophageal Reflux Disease. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008: chap 42.
Reviewed By: Linda Vorvick, MD, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
