A hiatus hernia, or hiatal hernia, is when part of the stomach squeezes into the chest through an opening in the diaphragm called the hiatus.
There are two main types of hiatus hernia:
- sliding hiatus hernias – hernias that move up and down, in and out of the chest area (more than 80% of hiatus hernias are this type)
- para-oesophageal hiatus hernias – also called rolling hiatus hernias, this is where part of the stomach pushes up through the hole in the diaphragm next to the oesophagus (about 5-15% of hiatus hernias are this type)
Patients with no symptoms and small sliding hernias don’t require surgery. Likewise asymptomatic or minimally symptomatic patients with large sliding hernias don’t always require surgery.
Most symptomatic rolling hernias require surgery, to prevent severe twisting and the need for emergency surgery. Even patients with no symptoms who have rolling type hernia should be considered for surgery, as there is a risk of twisting and strangulation. However, there age and general fitness should be evaluated carefully.
Patients with hiatus hernias are offered surgery if they:
- Suffer from severe symptoms of GORD and are suitable for surgery
- Have symptoms which don’t improve on medical therapy. These are typically regurgitation, volume reflux or dysphagia.
- Have a hernia which twists or is a risk of twists (gastric volvulus). This can happen with a para-oesophageal type hernia.
Surgery is usually performed laparoscopically. However, open surgery may be required, especially in patients who have had previous upper abdominal surgery (due to adhesions and scar tissue), or a recurrent hiatus hernia after a previous attempt at repair. Emergency procedures can also be performed laparoscopically, but have a much higher risk of needing open surgery, especially if the stomach is damaged due to a severe twist.
The operation involves:
- Carefully removing the sac (the lining) of the hernia. This is important to avoid the risk of the hernia coming back.
- Fully freeing the stomach and any other contents of the hernia so it lies in the abdomen and not in the chest. After the this the lower part of the oesophagus (gullet) should lie back in the upper abdomen.
- Repairing the hole in the diaphragm by narrowing it with several stitches or sutures. The sutures are non-absorbable.
- A fundoplication is usually also performed to reduce the risk of reflux and also to suture the stomach to the diaphragm to try to reduce the risk of recurrence.
The most important thing during the early recovery is to ensure no severe retching or vomiting occurs. This is achieved by administering regular anti sickness medication. Vomiting or retching can put stress on the repair and stress the stitches. This could potentially lead to a early recurrent hernia which would require further surgery.
Hiatal Hernia Symptoms:
Some hiatus hernias are really small and don’t cause much in the way of symptoms. When they get a bit more sizeable they considerably weaken the valve at the lower gullet. This makes it ineffective in stopping acid coming up from the stomach. In this case the most common symptom is acid heartburn or reflux. This is often worse on lying down or after a heavy meal. Hiatus hernias which are much larger can cause vomiting, difficulty swallowing, regurgitation, chest pain and upper abdominal discomfort.
Hiatal hernias most commonly involve the stomach as the organ which comes up through the natural hole in the diaphragm called the hiatus. Really big hiatus hernias can have other abdominal organs in them, such as small bowel, colon or even the spleen or pancreas in rare cases.
Hiatal hernias can be assessed either with endoscopy or a dye test called a barium swallow. Massive hiatus hernias may need a CT scan to assess for the precise anatomy and contents of the hernia… Especially when corrective surgery is required. Even large hiatus hernias can be repaired using keyhole surgery to speed up the recovery process.