Any time an internal body part pushes into an area where it doesn’t belong, it’s called a hernia. The hiatus is an opening in the diaphragm – the muscular wall separating the chest cavity from the abdomen. Normally, the esophagus goes through the hiatus and attaches to the stomach. In a hiatal hernia, the stomach bulges up into the chest through that opening. There are two main types of hiatal hernias: sliding and paraesophageal (next to the esophagus).
In a sliding hiatal hernia, the stomach and the section of the esophagus that joins the stomach slide up into the chest through the hiatus. This is the more common type of hernia. These sliding hiatal hernias are a risk factor for gastroesophageal reflux disease (GERD), and many patients with hiatal hernias suffer from GERD symptoms such as heartburn.
The paraesophageal hernia is less common, but is more cause for concern. In many patients, paraesophageal hernias may not cause any symptoms for the patient. These asymptomatic hernias can be safely observed and do not require surgery. When a paraesophageal hernia begins to cause symptoms (chest pain, upper abdominal pain, difficulty swallowing), these are usually repaired. Symptomatic paraesophageal hernias are at higher risk for progressing to incarceration (stomach gets stuck resulting in obstruction) or ischemia (blood supply to the stomach is cut off) resulting in the need for emergency surgery.
What is GERD?
Gastroesophageal reflux disease (GERD) is a digestive disorder that is caused by gastric acid flowing from the stomach into the esophagus.
Gastroesophageal refers to the stomach and esophagus, and reflux means to flow back or return. Gastroesophageal reflux is the return of acidic stomach juices, or food and fluids, back up into the esophagus. After food passes through the esophagus into the stomach, a muscular valve called the lower esophageal sphincter (LES) closes, preventing the movement of food or acid upward. Gastroesophageal reflux occurs when the LES relaxes inappropriately, allowing acid from the stomach to flow backward into the esophagus.
Heartburn, also called acid indigestion, is the most common symptom of GERD.
If left untreated, gastroesophageal reflux can cause esophageal ulcers, esophageal bleeding, and narrowing of the esophagus (peptic stricture).
A hiatal hernia may be associated with GERD. Severe heartburn may also result from hiatal hernia. A hiatal hernia is caused by an opening in the diaphragm, a flat muscle that separates the chest from the abdomen, allowing a portion of the stomach to protrude into the chest. This condition can then cause the LES to fail. Although most cases of gastroesophageal reflux are caused by a weakened valve, there are other causes that need to be assessed by your doctor.
How is GERD usually treated?
Treatment can include lifestyle changes, such as weight reduction, avoiding certain types of food and taking medications to alleviate symptoms. Surgery may be an option when treatment with medications does not completely relieve symptoms. It’s also a good option for patients whose symptoms are well controlled but who don’t want to take medication, and for patients with complications of reflux disease, such as ulcers, strictures or Barrett’s esophagus.
Anti-reflux operations (Nissen fundoplication) may help patients who have persistent symptoms despite medical treatment.
What is Nissen fundoplication?
During the fundoplication surgery, the surgeon improves the natural barrier between the stomach and the esophagus by wrapping a part of the stomach known as the gastric fundus around the lower esophagus. This prevents the flow of acids from the stomach into the esophagus, and strengthens the valve between the esophagus and stomach, which stops acid from backing up into the esophagus as easily. This procedure is often done using a laparoscopic surgical technique. It can also be done as traditional (open) surgery.
How is the laparoscopic technique performed?
A laparoscope is a fiber-optic instrument that is inserted in the abdominal wall. This device transmits images from within the body to a video monitor, allowing the surgeon to see the operative area on the screen.
During the laparoscopic Nissen fundoplication procedure, surgeons use small surgical tools and a laparoscope to repair the muscle that separates the stomach and esophagus.
How long will I have to stay in hospital? When can I resume normal activities?
The laparoscopic surgery often requires a hospital stay of only 23 hours. You should be able to return to normal activities between one and two weeks, compared with four to six weeks for traditional surgery.
Who are good candidates for the procedure?
Surgical candidates are those whose heartburn is not well controlled with medicine, those who want to fix the problem without having to take medicine long term, and those who are having complications from reflux, including ulcers, strictures, hernias or Barrett’s esophagus.
What can I expect before and after the surgery?
Lifestyle and dietary adjustments that are needed for about six weeks following surgery. They are advised to eat smaller amounts of food at each meal, to chew their food well, and avoid chewing gum and drinking carbonated beverages, to make sure the surgery will heal properly.