Hiatal Hernia Repair

Hiatal hernia is formed when the part of the stomach or all of it gets into the thoracic cavity through the oesophageal opening of the diaphragm. It is associated with obesity or previous surgery on the associated structures. Most of the patients with is condition will complain of heartburns because of the acid reflux due to either the incompetent lower oesophageal sphincter or the anatomical placement of the sphincter that permits acid reflux as seen in the case of the hiatal hernia.

1. Diagnosis and Surgical Treatment of Hiatal Hernia

Surgical resection is rarely required in this condition especially if the medical therapy is adequately working, but if the condition is associated with a volvulus formation or extreme gastroesophageal reflux where the medical treatment doesn’t work surgery is indicated. This condition mainly occurs in elderly patients.

Various radiological studies such as the barium swallow are used to diagnose these conditions. The surgical treatment of this condition involves the reduction of the stomach into the abdominal cavity and repair of the diaphragmatic orifice.

2. Indications

Surgery of this condition is rarely indicated, but if the hiatal hernia is associated with volvulus of the intestines or the medical treatment of the Gastroesophageal reflux associated with the hiatal hernia fails. Symptomatic hernias are a strong indicator for surgery because they are normally associated with gastric perforation or gangrene which most of the times is quite fatal.

3. How is the procedure done

The procedure can be either done laparoscopically or through laparotomy. The laparoscopic approach is only indicated for a small hiatal hernia as large ones can be particularly difficult to reconstruct and reduce. The laparotomy approach involves an open incision on the abdomen then reducing the hernial contents into the abdomen. Fundoplication might be done at this point to take care of the gastroesophageal reflux. Thereafter the surgeon repairs the opening on the diaphragm through which the intestinal contents herniated, a fiber meshwork might be used at this point to reinforce the repair. The final suturing back of the abdominal wall is done carefully. The laparoscopic approach is almost similar to the laparotomy but it consists of about 5 small holes on the abdomen which are used to insert the appropriate surgical instruments to pull back the stomach and its contents into the abdominal cavity, repairing the hernia and then reinforcing it if necessary.

4. Risks

Complete closure of the hernia defect can be difficult and some surgeons normally employ other surgical procedures such as Nissen fundoplication or using a meshwork fiber at the hiatal opening to prevent the recurrence of the condition and addressing some of the associated clinical signs and symptoms. There is a risk of secondary injuries during the surgical procedure. It might involve the thoracic or abdominal organs during the surgical procedure. Great care and preparation should be taken to avoid this. The open approach carries a greater risk of infections and future hernias (incisional hernias) as well as excessive bleeding during the surgery.

5. How you prepare for the surgery

The caregivers will assess if you are fit for the surgery particularly to prevent the adverse effects of the anesthesia and the surgery itself. The patient should have gotten adequate antibiotic cover before the surgical procedure to avoid the risk of portal pyemia. You are required to show up to the health care facility about a day to the surgery. This will give the caregivers enough time to run the lab blood tests required and other tests that might be required before the surgery. As of any surgical procedure that you’ll be required to be under general anesthesia, the patient is required to fast for about 8-12 hours to avoid complications of the anesthesia. An intravenous line is required to feed the required drugs into the body system of the patient. A water drip may or may not be employed. Because of the nature of the surgery, the patient is required to have a temporary urinary catheter to deliver the formed urine from the urinary bladder to prevent the bladder from becoming overfull during the surgery. The patient is required to avoid taking alcohol or smoking weeks before the surgery. In addition to this, the intake of other medication that might interfere with the clotting process is also contraindicated; consultation with the doctor if using these types of medication before surgery and before stopping them is mandatory.

6. Recovery after surgery

The patient should be advised on the diet. The first aim is to make sure that the stomach is not greatly distended by uncontrolled eating shortly after surgery; therefore the patient is required to take only small frequent meals to aid the healing process of the stomach. Secondly, unless allergic to protein, the patient is supposed to have a high protein diet because of the healing process. A balanced diet is advised and the protein should be in excess. The patient should take the medication and the advice given by the doctor such as taking frequent walks to prevent the formation of blood clots which could be potentially fatal. This also includes taking of the blood thinners in the case of prolonged immobilization. Avoid heavy lifting or any other strenuous exercise until the patient is fully healed. The patient should be discharged from the hospital in less than 3 days and fully healed at home in about 2 months and resuming their normal activities.

7. Outcomes after surgery

The hiatal hernias have a moderately high chance of recurrence and especially a high recurrence of the gastroesophageal reflux especially if the hiatal opening has not been reinforced well during the surgery. Other than that, the surgery is fairly straight forward and uncomplicated with a more than 90% success rates.

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