Friday, April 19, 2024

Surgery For Hiatal Hernia Repair

How Is Surgery For A Hiatal Hernia Performed

Hiatal Hernia Repair & LINX to Treat Reflux Animation

Surgery for repairing a hiatal hernia involves:

  • Pulling the hiatal hernia back into the abdomen.
  • Improving the valve at the bottom of the esophagus.
  • Closing the hole in the diaphragm muscle.

During surgery, your surgeon will wrap the upper part of the stomach around the lower portion of the esophagus. This creates a permanently tight sphincter so that stomach contents will not move back into the esophagus.

A laparoscopic surgery is done through several small incisions instead of one big cut. This is considered a minimally invasive option. The specific laparoscopic procedure used to repair a hiatal hernia is called the Nissen fundoplication. This procedure creates a permanent solution to your hiatal hernia symptoms. During the procedure, your surgeon will make five or six tiny incisions in the abdomen. The laparoscope and other surgical instruments are inserted through the small incisions. The fundus is wrapped around the esophagus and the sphincter is tightened during surgery. The advantages of laparoscopic surgery compared to an open surgery include:

  • Smaller incisions.

How Does Hernia Surgery Work

For a laparoscopic repair, three or four incisions, the largest of which is half an inch, are typically made on the side of the abdominal wall. A laparoscope, or thin telescope with a light on the end, is passed through. The hernia hole, or defect, is covered with mesh and affixed with staples, essentially serving as a patch.

With open surgery, the size of the incision is determined by the size of the hernia. For example, a small hernia might only require an incision of half an inch.

Most hernias, regardless of the type of surgery, are repaired with mesh reinforcements made from synthetic or biological materials. Mesh is favored over stitches in many instances, except for very small hernias.

What Are Different Types Of Hernia Surgery

Depending on the type of hernia and its size, doctors may treat it with either minimally invasive, laparoscopic procedures or with traditional open surgery. General anesthesia is used in both approaches.

As a general rule, open surgery is used for hernias that are very small or very large. Those that fall in between can be treated laparoscopically.

Don’t Miss: Plastic Surgery Before And After Celebrities

Assessing The Risk For Elective Surgery

Despite the low modern rates of morbidity and mortality, surgical intervention is not without complications. PEH surgery complications can include visceral injury, vagal nerve injury, pneumothorax, and mediastinal hemorrhage, among others . When considering the routine repair of an asymptomatic hernia, it is important to identify important risk factors of the patient. This is both for optimization and for the informed consent discussion.

As was previously mentioned, Jassim et al. found that overall risk of complication during and following elective and non-elective PEH repair was associated with chronic lung disease, electrolyte disorders, and weight loss/malnutrition. Lower rates of complication were significantly associated with female sex, elective and laparoscopic procedures . Increasing age was also associated with an increased overall risk of complication and mortality following elective and non-elective PEH repair.

Augustin et al. found an inverse relationship between BMI and mortality. Their study found that BMI 25-50 and BMI 30 were significantly protective of mortality . Frailty and preoperative sepsis increased the odds of mortality.

What Should I Expect After Laparoscopic Hiatal Hernia Repair

Figure 13.3 from Hiatal Hernia Surgery
  • You will need to do deep breathing exercises after your surgery to decrease your risk for a lung infection. Deep breaths help open your airway. These exercises will be painful because they put pressure on your incisions. You will be shown how to hold a pillow while you do breathing exercises to help decrease pain.
  • You may need to follow a soft diet for up to 4 weeks after your surgery.
  • Do not drive for a week after your surgery. Do not lift heavy objects. Your healthcare provider will tell you when you can return to your daily activities.

Recommended Reading: Si Joint Surgery Success Rate

Major Intraoperative And Mesh Related Complications

A review of 28 cases of complications from meshes deployed at the hiatus was published by Stadlhuber in 2009 . Seventeen of those patients presented with mesh erosions and nine of them required major foregut resection: six esophagectomies, two partial gastrectomies and one total gastrectomy. Interestingly, whilst 75% of those meshes were synthetic , the rest were from biological mesh . A subsequent review a decade later has again confirmed that PTFE and PP are associated with erosions with devastating consequences .

Whilst mesh erosions present late, there are other complications that can occur intraoperatively or become obvious in the early post-operative period. These are generally iatrogenic injuries associated with the extensive dissection required for LHH. Leeder reported two esophageal perforations which were repaired intraoperatively. Watson declared two perforations, one from a bougie the other was noted on the third postoperative day. Casteljins reported an intraoperative esophageal perforation that required stenting, with subsequent need for resection and conduit formation . Luckily those complications are not very common. A review of the literature on LHH repair shows that the esophageal perforation and erosion rates were at< 0.5% and< 0.75% respectively. Most patients recovered from the repair.

What Is Surgery Like For Inguinal Hernias

Laparoscopic Surgery. After making three small incisions, surgeons go behind layers of the abdominal wall muscles and lay reinforcement mesh between them.

Patients recovering from laparoscopic inguinal hernia surgery typically go home the same day as surgery and can expect to take pain medications for three to five days. They are restricted from lifting anything more than 20 pounds for two weeks. Depending on the patient’s job, he or she may return to work after a week or two.

After about a month, most patients feel fine and are back to normal.

Open Surgery. A single incision is made in the groin, and if the hernia is bulging out of the abdominal wall or into the inguinal canal, it is pushed back. Mesh is placed over the weakened area.

Patients recovering from open surgery for an inguinal hernia can expect to stay in the hospital for two to three days. Most patients take pain medication for a few days and depending on the patient’s job, he or she may return to work after a week or two.

Don’t Miss: How Much Does Umbilical Hernia Surgery Cost

Timing Of Surgery For Acutely Symptomatic Patients: Acute If You Must Subacute Staged Approach If You Can But Avoid Prolonged Delayed Repair

Patients with large hiatus hernia who present acutely need careful assessment. If they are fit to undergo an operation, then it needs to be offered. There is evidence to show that a simple conservative approach in such symptomatic patients has a risk of mortality of 16% . However, there is also a 16% risk of death associated with acute intervention. This is due to the significant complications that those patients present with , which leads to significant physiological compromise peri operatively. In addition, these patients are generally elderly with significant comorbidities. So, is there a way of improving on the mortality of those who need urgent intervention? There may be a role for a subacute staged approach for those who are not in an immediate organ threatening situation. Two series looking at those who present acutely with large hiatal herniae found that only less than 12.5% required an emergency operation, with the rest being able to proceed to semi-elective or elective repair with no increase in mortality . The delayed strategy includes decompression, restoration of physiological deficits, institution of enteral nutrition, careful anaesthetic evaluation and referring the patient to an experienced team of laparoscopic surgeons for the repair. Interrogation of the NSQIP database however suggests that the delay should be used for patient optimisation but that a prolonged delay will impact adversely on patient outcome .

What Are The Symptoms Of A Hiatal Hernia

Hiatal Hernia Repair Animation

Many people with a hiatal hernia never have symptoms. Some people with hiatal hernia have some of the same symptoms as gastroesophageal reflex disease . GERD occurs when digestive juices move from the stomach back into the esophagus. Symptoms of GERD include:

  • Bitter or sour taste in the back of the throat.
  • Bloating and belching.
  • Discomfort or pain in the stomach or esophagus.

Although there appears to be a link between hiatal hernia and GERD, one condition does not seem to cause the other. Many people have a hiatal hernia without having GERD, and others have GERD without having a hiatal hernia.

Another symptom of a hiatal hernia is chest pain. Since chest pain can also be a symptom of a heart attack, its important to contact your healthcare provider or go to the emergency room if you experience any chest pain.

Don’t Miss: Southwest Oral And Maxillofacial Surgery

Recovery In The Hospital

As youre recovering from surgery in the hospital, youll be given medications to manage pain. Some patients feel pain or discomfort due to the insufflation, but this can be managed and subsides within a few days.

During this time, patients are encouraged to get up and walk a little, which may take some assistance at first. This helps prevent blood clots from forming.

Can We Operate On Elderly Patients The Risks Are High And The Key Is Careful Selection

There are a few factors intrinsic to laparoscopic LHH repair that make the endeavour fraught with risks. The operation itself can be prolonged, which in turn can have adverse effect on respiratory and cardiovascular system of those patients who often have underlying co-morbidities such as obstructive airways disease or cardiomyopathy. Mediastinal dissection with the risk of pleural breach causing a pneumothorax or pericardial injury can be poorly tolerated intra- or post-operatively.

A nationwide audit in the US showed an increased mortality rate of 15.6% when repair was performed in octogenareans. Another retrospective study comparing outcomes in age groups found not difference in mortality but showed that 13.3% of octogenareans required prolonged intubation and ICU stay . Interestingly, an assessment of the NSQIP database showed that it is not the absolute age but rather the frailty score, or physiological frailty, which is associated with increased complication and mortality rates .

Unsurprisingly, Oor et al. demonstrated that a strategy of operating on well selected patients can lead to a good outcome irrespective of age. There was no 30-day mortality in patients either over or below 70 years old who underwent repair of LHH. The only difference was that elderly patients had a longer length of hospital stay .

Recommended Reading: Transposition Of The Great Arteries Surgery

When Is Surgery For A Hiatal Hernia Needed

If the portion of the stomach entering the esophagus is being squeezed so tightly that the blood supply is being cut off, youll need to have surgery. Surgery may also be needed in people with a hiatal hernia who have severe, long-lasting esophageal reflux whose symptoms are not relieved by medical treatments. The goal of this surgery is to correct gastroesophageal reflux by creating an improved valve mechanism at the bottom of the esophagus. Think of this valve as a swinging door. It opens to let food pass down into the stomach and then closes to keep stomach contents from going back up the esophagus. When this valve doesnt work correctly, your stomach contents can go the wrong way and damage your esophagus. If left untreated, chronic gastroesophageal reflux can cause complications such as esophagitis , esophageal ulcers, bleeding or scarring of the esophagus.

What Is The Treatment For Chronic Gerd

Laparoscopic Repair of Hiatal Hernia

The treatment for GERD when medication and lifestyle choices have not been effective is a surgical procedure that is performed laparoscopically. Laparoscopic Nissen fundoplication surgery is considered the Gold Standard in GERD surgical treatment and is performed under general anesthesia to repair the LES valve at the junction of the stomach and esophagus. Often during the same surgery, a hiatal hernia repair is done to reposition the stomach so it does not protrude into the diaphragm.

Recommended Reading: Grants For Skin Removal Surgery

Laparoscopic Hiatal Hernia Repair

About 15 percent of Americans suffer from Hiatal Hernias. The condition occurs when part of the stomach pushes upward through the diaphragm through a small opening called the hiatus. Small hiatal hernias are common many do not even know they have them. However, if the hernia is large, the patient will suffer a range of gastrointestinal problems, including chronic acid reflux, heartburn and chest pain. These large hiatal hernias are also often accompanied by belching and nausea. If these symptoms have begun to interrupt your life, see your doctor or consult an expert gastroenterologist at The Jackson Clinic, a minimally invasive option may be available.

Hiatal hernias are caused by the weakening of muscle tissue around the hiatus, whether from injury to that area, applying regular pressure to the surrounding muscles, or a natural muscular weakness. Particularly at risk for developing hiatal hernias are the obese, smokers and people over 50.

For many people suffering from hiatal hernia pain and discomfort, a combination of medication and lifestyle changes often alleviates symptoms. Doctors may recommend:

Certain lifestyle changes can also have a dramatic effect on the experienced symptoms of hiatal hernia. The Mayo Clinic suggests:

For a small number of hiatal hernia cases, surgery is required. Generally, this surgery is reserved for those whose symptoms are not relieved by medication or altering lifestyle.

How Do I Get Ready For A Hiatal Hernia Repair

Your healthcare provider will explain the surgery to you. Be sure to ask any questions you may have.

Tell your healthcare provider about all the medicines you take. This includes over-the-counter medicines such as ibuprofen. It also includes vitamins, herbs, and other supplements.

You will be asked to sign a consent form that gives your permission to do the surgery. Read the form carefully and ask questions if something is not clear.

Your healthcare provider will ask questions about your past health. He or she may also do a physical exam. This is to be sure you are in good health before having the surgery. You may also have blood tests or other tests.

Tell your healthcare provider if you:

  • Are pregnant or think you may be.
  • Are sensitive or allergic to any medicines, iodine, latex, tape, or anesthesia drugs .
  • Have a history of bleeding disorders or are taking any blood-thinning medicines, aspirin, or other medicines that affect blood clotting. You may have to stop taking these medicines before your surgery.

You must not eat or drink anything for 8 hours before the surgery. This often means no food or drink after midnight.

Your healthcare provider may have other instructions for you based on your medical condition.

Recommended Reading: Before And After Gastric Sleeve Surgery

Has Anyone Had Surgery To Repair Hiatal Hernia

Has anyone had surgery to repair hiatal hernia?

I had hiatal hernia repair surgery in August of 2015. Unfortunately, the vagus nerve during surgery was damaged and now I have gastroparesis. This disease has changed my life! My diet is very limited and even though I am careful about what I eat, I still have bad stomach days when I am unable to do much because of the pain. The hiatal hernia was pressing against my lung and the surgery resolved that problem and I no longer have reflux but the gastroparesis is worse than any of the problems I had before the hiatal hernia repair surgery.

I had hiatal hernia repair surgery in August of 2015. Unfortunately, the vagus nerve during surgery was damaged and now I have gastroparesis. This disease has changed my life! My diet is very limited and even though I am careful about what I eat, I still have bad stomach days when I am unable to do much because of the pain. The hiatal hernia was pressing against my lung and the surgery resolved that problem and I no longer have reflux but the gastroparesis is worse than any of the problems I had before the hiatal hernia repair surgery.

Hello @tlv68,

@tlv68, could you tell us a little more about your condition? How have you managed so far?

So To Mesh Or Not To Mesh Lhh

Hiatal Hernia Repair FAQ

Mesh reduces total recurrence significantly with a lesser impact on reoperation rate. The relative benefit of PFTE/PP/SIS has not been proven on comparative studies. Overall, the mortality and major morbidity of LHH mesh repair is acceptable. Although rare, the risk of erosion from synthetic mesh is concerning and it is now time to consider other alternative. A close look at long-term study with synthetic and biological meshes suggests that the future may lie with biosynthetic meshes .

Table summarises the timing of publication of meshes used in LHH. The evidence on BSM is dominated by absorbable BioA, with four cohort and only one comparative study. New data on the more recent BSM of Phasix ST is now emerging, with a recent cohort study on LHH showing promising result, although follow up was short . Phasix ST has an improved profile compared to BioA as it handles better and is reabsorbed within 18 months, versus 6 months. The construction of well powered RCTs involving biosynthetics with long term follow up and paying particular attention to standardization of variables will hopefully determine if newer BSMs are in fact the answer we have been looking for.

You May Like: Pancreatic Cancer Surgery Survival Rates

Need For Hernial Sac Dissection

In 1999 Watson et al. reported an extrasaccular approach to mediastinal dissection of a large hiatal hernia . They penetrated the sac close to the edge of the hiatal defect and then entered the mediastinal areolar plane before bringing the whole sac and its contents back into the abdominal cavity. This avoided traumatic manipulation and injuries to the stomach. A stomach first approach is more difficult especially as it is adherent to the sac posteriorly. Such an approach would also be associated with an increased risk of vagal injuries. They found that the conversion rate to open was reduced from 40 to 9% with this technique.

Complete hernial sac dissection and excision is necessary but could theoretically lead to distal esophageal devascularization and potentially leaks. In fact, in a series on LHHs there were only two leaks noted in 131 patients. Those leaks were delayed , which makes them more likely to have been secondary to esophageal suturing performed during the Toupet fundoplication . Whilst sac excision is preferable, the extent of its dissection is dependent on the likelihood of a safe and uncomplicated excision, indication for surgery and skillset of the surgeon.

Latest news
Related news