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Hiatus hernia is a weakening of diaphragm muscles, leading to sliding of your stomach towards the chest. This leads to weakening of the valve at the lower end of the food-pipe (LES valve). This affects the functioning of this LES valve and at times even that of esopahgus and stomach. This eventually leads to a variety of different symptoms in varying severity. Although not a very serious condition, at times affects patients diet and nutrition and quality of life. In such situation patients may need a surgery, which is done by a laparoscopic method.
Hernia means a weakening of muscle leading to a defect or a hole in that muscle, allowing normal body organs to come out to it, leading to many problems. The commonly seen hernia occurs due to a defect in the muscle of the tummy wall, due to various reasons, allowing intestines and tummy fat to come out and cause a bulge. As they occur on the tummy wall, they can be seen as a bulge and can be easily diagnosed by a sonography. The common hernia are Inguinal and femoral(groin), umbilical (navel), incisional(at previous surgery site) and epigastric (upper tummy).
A hiatus hernia is a hernia where there is a weakening of the diaphragm muscle leading to enlarging of the normal opening through which the esopahgus (food-pipe) enters the tummy from the chest. This widening or enlarging of the opening, which is commonly called esophageal hiatus, allows the upper part of the stomach to be pushed up towards the chest. We call this process, herniation of the stomach into the chest. Because the pressure inside the tummy is high and that in the chest is negative (the body’s mechanism to allow the lungs to expand easily, thus help us breathe with less effort), there is a natural tendency for the stomach to move up, in situations where the hiatus (opening in diaphragm) becomes large. The pressure in the tummy also increases dynamically whenever we do strenuous activity, also during normal activities like coughing, sneezing, passing motion and urine.
Thus, in patients with a hiatus hernia, the upper part of the stomach along with the LES valve moves up and down with different activity. Any activity that increases the pressure in the tummy will push the stomach up in the chest. The same thing happens during deep inhalation when the pressure in the chest goes down for the lungs to expand. The stomach then again moves back to its normal position when the tummy pressure goes down. Many patients who have had a hiatus hernia for many years, have almost half or more of their stomach moved inside the chest. In such patients, many a time the stomach constantly remains in the chest leading to severe symptoms.
The common symptoms of patients with a hiatus hernia are:
Like other hernias, in a hiatus hernia, no bulge is visible. Clinical examination by a doctor is also not a way to diagnose a hiatus hernia. Although, from your history, that is the pattern of your problems, a doctor can have a suspicion about the possibility of a hiatus hernia. In such a situation, further tests are needed. The tests needed are
All patients who have a hiatus hernia on endoscopy do not need surgery. All patients who have severe symptoms, or have problems for many years may need a surgery. All such patients having long-term or severe problems should be evaluated with further tests to decide if surgery is needed or not. Patients having a large hiatus hernia also needs surgery, at times even if their symptoms are less severe and/or controlled with medications.
Some patients having small hiatus hernia, but persistent symptoms of GERD or acid reflux may need surgery. Many such patients are having good control of their symptoms on medications, but are dependent on medications. In such a situation, patients can choose a surgical option rather than taking lifelong medications. Some patients may also have side effects of medications and hence are forced to opt for surgery. For all such patients, a proper evaluation by an esopahgeal manometry and 24 hr pH Impedance study should be done. Surgery is generally only indicated with GERD is confirmed on pH Impedance study.
Surgery for Hiatus hernia is done by a laparoscopic method. In this surgery, 4-5 small cuts are made (one is 1cm and others are 5 mm) to perform this surgery by a keyhole method. During this surgery, first, the part of your stomach and LES valve that has moved up in the chest is brought back to the tummy. Then the hiatus (the hole in the diaphragm for the food pipe) is repaired with sutures. The hiatus is made of a normal size with sutures. The sutures are permanent and with remain lifelong to give strength to your diaphragm. Don’t worry, as these permanent suture will not cause any harm or problems for you and are needed to have a good strength to the diaphragm.
Occasionally, if we feel that your diaphragm is too weak, or the defect is too big to be closed simply by sutures, then a mesh may be needed to repair it. Like other hernias, placing a mesh is not a routine and is very very rarely needed. When not needed, then mesh is avoided as it has a possible change of damaging your food pipe. Thus, is it used as the last resort when using a mesh is a must. This is also a reason why we feel, that surgery should not be delayed to the extent that the defect becomes too big and placing a mesh becomes a necessity.
Once the hiatus is repaired, a new valve is created by wrapping the upper part (fundus) of your stomach around the food pipe and stitching it in place. This is called a wrap or a fundoplication. This is needed to prevent the reflux of food and acid in the food pipe.
Complete surgery including the anaesthesias will take about 1.5-2 hours of time. This surgery can be very safely done with good results under expert hands.
As this surgery is done by a laparoscopic method, the early recovery after surgery is quiet pain-free and smooth. All our patients are able to get out of bed and walk around just in few hours after surgery. Most don’t need injectable medications after surgery, painkiller tablets are started on the same day, once oral liquids are allowed. We allow taking liquids by mouth 3-4 hours after surgery, and once they are comfortable soft diet is also started the same day. Early mobilisation (getting out of bed and moving around) and oral diet intake, not only make the patient feel good but also help in early recovery. Thus, when the patient is discharged the next day, we are reassured that the patient is not having significant difficulty in eating.
If we talk about the long-term results, in improving their primary problems, then studies show 90-95% symptom control after 10 years of surgery. Certainly, for good results, we need to do proper evaluation before surgery to make sure that surgery is needed. Also to make sure that the patient’s current problems are because of the hiatus hernia and hence will improve after surgery. Also, the surgery should be done by an expert surgeon and his team to get the best results. The efforts do not end here, and a good follow-up from the surgical team and changes in diet and lifestyle and stress management from the patient are needed to get the best possible outcome.
We at ADROIT make sure that above all aspects are done to the best possible level. This is the reason we see excellent results in our patients. Hence we have a large no of highly satisfied patients who recommend us generously.
As in this surgery, we are doing a repair of your hiatal muscles, and we want the area of repair to get time to heal properly. Hence we should avoid all the activities that would cause pressure and train on your diaphragm muscles. Thus we advise all our patients to avoid lifting heavy weight (anything more than 5kgs, you can carry your laptop or office or tiffin bag) for an initial 3 months after surgery. We also advise our patients to avoid all activity, exercise and sports that are likely to cause increased pressure in their tummy or the initial 3 months. We also restrict driving a 2-wheeler for an initial 1 month after surgery. For the initial 3 months patients should avoid sleeping on their tummy, but sleeping on one side (both right and left) in not a problem and can be done from the first day.
Although, walking and resuming your other routine activities, even climbing of stairs can be started on the same day of surgery. Routine household and office work can be resumed in a couple of days as you feel comfortable. Light jogging can be resumed after 2-3 weeks, and after a month cycling can also be resumed. You can watch our video on exercise and activity after hiatus hernia surgery on our YouTube channel.
If you are having severe symptoms due to a hiatus hernia, then you can end your suffering with a surgery. Also, if you have been taking medications for the same for a long time, then surgery may be a better option compared to lifelong medications. Certainly, you need to consult the expert to decide if surgery is indicated in your case. Feel free to connect to us and we will try our best to end your suffering.
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Dr Chirag Thakkar is a gastrointestinal surgeon. He has been carrying out gastrointestinal and weight loss surgery for the past 18 years. Surgery for GERD, hiatus hernia and Obesity are his core areas of interest and expertise.
Dr.Chirag Thakkar
