Sliding- This is the most common type and is the one most people refer to when they say they have a hiatal hernia. The most common symptom is reflux and the only reason to repair this type is for severe reflux or complications from the reflux. This is discussed in great detail on our page titled Gastroesophageal Reflux Disease (GERD). I will refer you to that link for more information.
Paraesophageal Hiatal Hernia - This type of hernia is less common and typically occurs in elderly patients. Some patients present with reflux but more commonly it is dysphagia or food “sticking” in the esophagus after swallowing. Other signs and symptoms associated with these hernias are anemia, shortness of breath, substernal chest pain, and bloating. (figure 4 image C)
Hiatal Hernia Diagnosis
Many times these are found incidentally as many are asymptomatic. A simple chest x-ray will sometimes show a large gas bubble (the stomach) in the chest behind the heart. Upper endoscopy, placing a camera with a light into the stomach, is another way to visualize the hernia and any associated pathology. The best way to determine the extent of the hernia is by esophagogram (Upper GI- UGI, or Barium Swallow). (figure 3) This test requires drinking barium to outlined the esophagus and stomach while viewing it under fluorscopy (video x-ray).
Hiatal Hernia Surgey
Indications for Surgery
The main reason to consider surgery in these patients is persistent symptoms. Hernias that are found incidentally don’t necessarily require repair as only 2% will eventually have severe complications.
- Dysphagia- difficulty swallowing
- Anemia - Low hematocrit or low blood. Ulcers in the stomach caused by the hernia lead to chronic bleeding
- Pain - sometimes these hernias will lead to obstruction which can cause chest pain
- Vomiting - same etiology as for pain
- Shortness of Breath - when large these hernias take up space in the chest and decrease lung volume making it difficult to take a deep breath
Surgery is typically done laparoscopically in our practice and is now becoming standard of care. There was controversy in the past whether these hernias should be done through the chest or through conventional “open” surgery given the notoriously high recurrence rate. With newer techniques and attention to detail the laparoscopic approach is now just as reliable with fewer complications and faster recovery. Sometimes the hole in the diaphragm (the hernia) will need to be patched with a mesh (5-10%) to give it more strength and decrease recurrence rate. This decision is made at the time of surgery, adds some time 20-30 minutes to the procedure, but affects recovery time very little if at all.
- Done laparoscopically 5-6 incisions 0.5-1cm each
- Surgery lasts 1.5-2.5 hours
- The hernia and its “sack” are removed from the chest
- The esophagus is dissected so that 2-3 cm extends below the diaphragm
- The hiatus, hole in the diaphragm, is closed to prevent recurrence of the the hernia
- 5-10% of time this is reinforced with a biologic mesh
- The stomach is wrapped around the esophagus to prevent subsequent reflux
- The stomach is sewn to the diaphragm and anterior abdominal wall as extra support to prevent recurrence
Risks of Surgery
- Bleeding, Infection, or damage to other organs as can occur with any surgery
- Anesthetic complications - pre-operative evaluation and tests are done to minimize this risk
- Damage to the Vagus nerves - Given the size of the hernia, anatomy is distorted and these nerves can be damaged. This may result in diarrhea or delayed emptying of the stomach with nausea and vomiting. These symptoms are usually self-limited and resolve with dietary modification and time. Very rarely do they require any additional procedure(s) for treatment.
- Recurrence of hernia - all hernias regardless of where they occur have a known recurrence rate. Paraesophageal hernias have been reported to anywhere from 10-50%. Our rate is less than 5% as determined by Upper GI at 1 year after surgery.
- Pleural Effusion - this is a condition where fluid accumulates in the chest outside the lung. It will occur to some degree in everyone as a normal inflammatory process. Occasionally it will be large enough to cause symptoms and may need to be drained with x-ray guidance.
- Dysphagia- “food sticking” if this does not resolve with time then endoscopic dilatation can be done or rarely repeat surgery will be required.
Pre and Post Operative Instructions for Paraesophageal Hiatal Hernia Repair Surgery
- Discuss with your surgeon treatment options and ask any questions you might have with regards to that treatment.
- Sign consent for surgery confirming that you understand the potential risks and benefits of surgery and agree to proceed.
- Complete pre-operative testing including blood work, EKG or other tests your physician may order
- After lunch the day before surgery eat only a liquid diet and take 1 bottle of Magnesium Citrate at 2:00pm or after work. This will empty your colon making your surgery safer and decreasing issues with constipation post operatively.
- Shower with Hibiclense (anti-bacterial soap) the night before and morning of surgery to help decrease risk of wound infection. (It can be purchased at any pharmacy or may be given to you by hospital staff)
- Do NOT eat or drink anything after midnight before surgery. The stomach needs to be completely empty prior to surgery.
- Stop Aspirin 1 week prior, Plavix 10 days prior, and Coumadin (Wafarin) 5 days prior to surgery. Notify your surgeon if taking any other blood thinners for instruction on when to stop them.
- Stop Smoking 1 week prior to surgery
Day of Surgery
- Arrive at hospital at time instructed by office staff. A minimum of 2 hours prior to scheduled surgery time
- Nurses will prepare you for surgery with an IV and any pre-op medications that have been ordered.
- The anesthesiologist will talk to you about putting you to sleep in a room just outside the operating room.
- After surgery you will go to the recovery room for about 1 hour where you will be watched closely as you continue to wake up. Family members are not allowed in at this time.
- You will spend at least 1 night in the hospital.
After Discharge from the Hospital
- You are encouraged to walk and resume light activity when you return home
- No lifting over 20 pounds until you see your surgeon.
- Take pain medications as needed to allow increased mobility.
- Prevent constipation by drinking lots of fluid and if necessary taking a stool softener (Colace) or Milk of Magnesia as needed.
- Schedule a post-operative appointment for 2 weeks after surgery. Do this the day you get home or soon thereafter for ease of scheduling.
Call Your Doctor If:
- Persistent fever over 101 degrees F
- Significant bleeding
- Pain not relieved by medications or that is getting more severe
- Persistent nausea and vomiting
- Increasing redness or drainage from the incisions
- If unable to eat or drink liquids
- Constipation not relieved by stool softeners or Milk of Magnesia of 3 days duration
- Persistent cough or increasing shortness of breath